Online Referral
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<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"><img src="data:image/jpeg;base64,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"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">If you are experiencing a medical or mental health emergency, please call 911 immediately.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" er_fld_condfld="CST_36" er_fld_condvals="er_fld_showif_values=Suicidal+Ideation" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn"> ***PRIORITY REFERRAL***</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_60" er_fld_condvals="er_fld_showif_values=Hospital&er_fld_showif_values=Partial+Hospitalization&er_fld_showif_values=Residential+Treatment+Facility+(RTF)&er_fld_showif_values=Crisis+Residence+(CR)&er_fld_showif_values=Children's+Community+Residence+(CCR)"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn"> ***PRIORITY REFERRAL***</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">Children's Home of Poughkeepsie - Children's Way Counseling Center</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Was this referral made directly from a hospital setting?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="Emergency Department">Emergency Department</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="Inpatient Hospitalization">Inpatient Hospitalization</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="N/A">N/A</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></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Referral Source Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referral Source Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referral Source Organization</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 Number</label><input name="CST_4" 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 Address</label><input name="CST_1" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Client First Name</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 25%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required er_fld_width100" name="CST_10" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Client Phone #:</label><input name="CST_68" type="text" class=""></li><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="Prefer not to answer">Prefer not to answer</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_8" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_8_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Language"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Language</label><input name="CST_20" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Race"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Race</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="American Indian or Alaska Native">American Indian or Alaska Native</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="Asian">Asian</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="Black or African American">Black or African American</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" 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_55" value="Caucasian/White">Caucasian/White</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="Hispanic">Hispanic</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="Biracial">Biracial</label><label class="er_option"><input class="type_radio" type="radio" name="CST_55" value="Multiracial">Multiracial</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_55" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_55_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address 1</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address 2</label><input name="CST_39" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Address_Zip" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip</label><input name="CST_38" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Address_County"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">County:</label><select name="CST_66" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Albany">Albany</option><option value="Allegany">Allegany</option><option value="Bronx">Bronx</option><option value="Broome">Broome</option><option value="Cattaraugus">Cattaraugus</option><option value="Cayuga">Cayuga</option><option value="Chautauqua">Chautauqua</option><option value="Chemung">Chemung</option><option value="Chenango">Chenango</option><option value="Clinton">Clinton</option><option value="Columbia">Columbia</option><option value="Cortland">Cortland</option><option value="Delaware">Delaware</option><option value="Dutchess">Dutchess</option><option value="Erie">Erie</option><option value="Essex">Essex</option><option value="Franklin">Franklin</option><option value="Fulton">Fulton</option><option value="Genesee">Genesee</option><option value="Greene">Greene</option><option value="Hamilton">Hamilton</option><option value="Herkimer">Herkimer</option><option value="Jefferson">Jefferson</option><option value="Kings (Brooklyn)">Kings (Brooklyn)</option><option value="Lewis">Lewis</option><option value="Livingston">Livingston</option><option value="Madison">Madison</option><option value="Monroe">Monroe</option><option value="Montgomery">Montgomery</option><option value="Nassau">Nassau</option><option value="New York (Manhattan)">New York (Manhattan)</option><option value="Niagara">Niagara</option><option value="Oneida">Oneida</option><option value="Onondaga">Onondaga</option><option value="Ontario">Ontario</option><option value="Orange">Orange</option><option value="Orleans">Orleans</option><option value="Oswego">Oswego</option><option value="Otsego">Otsego</option><option value="Putnam">Putnam</option><option value="Queens">Queens</option><option value="Rensselaer">Rensselaer</option><option value="Richmond (Staten Island)">Richmond (Staten Island)</option><option value="Rockland">Rockland</option><option value="St. Lawrence">St. Lawrence</option><option value="Saratoga">Saratoga</option><option value="Schenectady">Schenectady</option><option value="Schoharie">Schoharie</option><option value="Schuyler">Schuyler</option><option value="Seneca">Seneca</option><option value="Steuben">Steuben</option><option value="Suffolk">Suffolk</option><option value="Sullivan">Sullivan</option><option value="Tioga">Tioga</option><option value="Tompkins">Tompkins</option><option value="Ulster">Ulster</option><option value="Warren">Warren</option><option value="Washington">Washington</option><option value="Wayne">Wayne</option><option value="Westchester">Westchester</option><option value="Wyoming">Wyoming</option><option value="Yates">Yates</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Consent to refer given by</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" value="Parent">Parent</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" value="Legal Guardian">Legal Guardian</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" value="Legal Authorized Representative">Legal Authorized Representative</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" value="Client (if 18 year of age or older)">Client (if 18 year of age or older)</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_14" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_14_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="Nothing" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label required">Consenter Name</label><input name="CST_50" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label required">Consenter Phone Number</label><input name="CST_51" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label required">Caregiver Name</label><input name="CST_15" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Caregiver Relationship to Client</label><select name="CST_52" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Biological Mother">Biological Mother</option><option value="Biological Father">Biological Father</option><option value="Foster Mother">Foster Mother</option><option value="Foster Father">Foster Father</option><option value="Adoptive Mother">Adoptive Mother</option><option value="Adoptive Father">Adoptive Father</option><option value="Grandparent">Grandparent</option><option value="Relative: Aunt/Uncle">Relative: Aunt/Uncle</option><option value="Relative: Sibling">Relative: Sibling</option><option value="Relative: Other">Relative: Other</option><option value="Other">Other</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Relative%3A+Other&er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Please specify relationship to client:</label><input name="CST_53" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="CC_EMail" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label">Caregiver Email</label><input name="CST_16" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label required">Caregiver Phone Number</label><input name="CST_17" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_14" er_fld_condvals="er_fld_showif_values=Parent&er_fld_showif_values=Legal+Guardian&er_fld_showif_values=Legal+Authorized+Representative"> <i class="fa fa-font"></i><label class="er_fld_label required">Caregiver Alternate Phone Number</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CustomField_Value_4"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Preferred Method of Contact</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Text">Text</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Phone Call">Phone Call</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Email">Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Mail">Mail</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_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Insurance Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="Nothing"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Please Select Insurance Type</label><select name="CST_41" class="er_fld_required"><option value=""></option><option value="Medicaid">Medicaid</option><option value="Child Health Plus">Child Health Plus</option><option value="Commercial Insurance">Commercial Insurance</option><option value="Self Pay">Self Pay</option><option value="Unknown at time of Referral">Unknown at time of Referral</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif sortable-chosen" draggable="true" style="width: 33.3333%;" map_to="CC_Medicaid" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Medicaid CIN Number</label><input name="CST_21" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's MCO/Insurance Provider</label><input name="CST_22" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_5" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Child+Health+Plus"> <i class="fa fa-font"></i><label class="er_fld_label required">Child Health Plus ID #</label><input name="CST_45" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Child+Health+Plus" style="width: 33.3333%;" map_to="Nothing"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's Insurance Provider</label><input name="CST_43" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Commercial+Insurance" map_to="Nothing"> <i class="fa fa-font"></i><label class="er_fld_label required">Insurance Company Name</label><input name="CST_61" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Commercial+Insurance"> <i class="fa fa-font"></i><label class="er_fld_label required">Policy Holder Name</label><input name="CST_62" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Commercial+Insurance"> <i class="fa fa-font"></i><label class="er_fld_label required">Policy Holder Relationship to the Client</label><input name="CST_63" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Commercial+Insurance" map_to="Nothing"> <i class="fa fa-font"></i><label class="er_fld_label required">Insurance Policy or Member ID Number</label><input name="CST_64" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=Commercial+Insurance"> <i class="fa fa-font"></i><label class="er_fld_label">Group Number (optional)</label><input name="CST_65" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Has the client been diagnosed with a mental health disorder?</label><select name="CST_47" class="er_fld_required"><option value=""></option><option value="Yes">Yes</option><option value="No">No</option><option value="Unsure">Unsure</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Diagnosis</label><input name="CST_23" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown sortable-chosen" draggable="true" style="width: 25%;" map_to="CustomField_Value_1"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">What school is the youth currently attending?</label><select name="CST_57" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Bennett Elementary School">Bennett Elementary School</option><option value="Cahill Elementary School">Cahill Elementary School</option><option value="Carmel High School">Carmel High School</option><option value="Chambers Elementary School">Chambers Elementary School</option><option value="Dutchess Alternative BOCES BETA">Dutchess Alternative BOCES BETA</option><option value="Dutchess BOCES Salt Point Education Center">Dutchess BOCES Salt Point Education Center</option><option value="Duzine Elementary School">Duzine Elementary School</option><option value="Edward R Crosby Elementary School">Edward R Crosby Elementary School</option><option value="Ellenville Elementary School">Ellenville Elementary School</option><option value="Ellenville Junior / Senior High School 7-12">Ellenville Junior / Senior High School 7-12</option><option value="Ernest C. Myer Elementary School">Ernest C. Myer Elementary School</option><option value="George Washington Elementary School">George Washington Elementary School</option><option value="Harry L. Edson Elementary School">Harry L. Edson Elementary School</option><option value="Highland Elementary School">Highland Elementary School</option><option value="Highland Falls Intermediate School">Highland Falls Intermediate School</option><option value="Highland High School">Highland High School</option><option value="Highland Middle School">Highland Middle School</option><option value="Homeschool">Homeschool</option><option value="Horizons-on-the-Hudson Magnet School">Horizons-on-the-Hudson Magnet School</option><option value="J. Watson Bailey Middle School">J. Watson Bailey Middle School</option><option value="John F. Kennedy Elementary School">John F. Kennedy Elementary School</option><option value="John G. Borden Middle School">John G. Borden Middle School</option><option value="Kerhonkson Elementary School">Kerhonkson Elementary School</option><option value="Kingston High School">Kingston High School</option><option value="M. Clifford Miller Middle School">M. Clifford Miller Middle School</option><option value="Marbletown Elementary School">Marbletown Elementary School</option><option value="Marlboro Elementary School">Marlboro Elementary School</option><option value="Marlboro High School">Marlboro High School</option><option value="Marlboro Middle School">Marlboro Middle School</option><option value="Middleway">Middleway</option><option value="Mt. Marion Elementary School">Mt. Marion Elementary School</option><option value="New Paltz High School">New Paltz High School</option><option value="New Paltz Middle School">New Paltz Middle School</option><option value="New Windsor School">New Windsor School</option><option value="Newburgh Free Academy (Main)">Newburgh Free Academy (Main)</option><option value="Newburgh Free Academy (North)">Newburgh Free Academy (North)</option><option value="Newburgh Free Academy (West)">Newburgh Free Academy (West)</option><option value="Onteora High School">Onteora High School</option><option value="Onteora Middle School">Onteora Middle School</option><option value="Orange-Ulster BOCES Arden Hill">Orange-Ulster BOCES Arden Hill</option><option value="Ostrander Elementary School">Ostrander Elementary School</option><option value="Phoenicia Elementary School">Phoenicia Elementary School</option><option value="Pine Bush Elementary School">Pine Bush Elementary School</option><option value="Pine Bush High School">Pine Bush High School</option><option value="Pine Island Elementary School">Pine Island Elementary School</option><option value="Pine Tree Elementary School">Pine Tree Elementary School</option><option value="Plattekill Elementary School">Plattekill Elementary School</option><option value="Riccardi Elementary School">Riccardi Elementary School</option><option value="Robert R. Graves Elementary School">Robert R. Graves Elementary School</option><option value="Rondout Valley High School">Rondout Valley High School</option><option value="Rondout Valley Intermediate School">Rondout Valley Intermediate School</option><option value="Rondout Valley Junior High School">Rondout Valley Junior High School</option><option value="Round Hill Elementary School">Round Hill Elementary School</option><option value="Saugerties High School">Saugerties High School</option><option value="Saugerties Junior High School">Saugerties Junior High School</option><option value="Ulster BOCES">Ulster BOCES</option><option value="Wallkill Senior High School">Wallkill Senior High School</option><option value="Woodstock Elementary School">Woodstock Elementary School</option><option value="Woodstock Day School">Woodstock Day School</option></select></li><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 25%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">What is the school district?</label><select name="CST_58" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Arlington Central School District">Arlington Central School District</option><option value="Beacon City School District">Beacon City School District</option><option value="Berkshire Union Free School District">Berkshire Union Free School District</option><option value="Brewster Central School District">Brewster Central School District</option><option value="Carmel Central School District">Carmel Central School District</option><option value="Chatham Central School District">Chatham Central School District</option><option value="Chester Union Free School District">Chester Union Free School District</option><option value="Cornwall Central School District">Cornwall Central School District</option><option value="Dover Union Free School District">Dover Union Free School District</option><option value="Ellenville School District">Ellenville School District</option><option value="Florida School District">Florida School District</option><option value="Garrison School District">Garrison School District</option><option value="Germantown School District">Germantown School District</option><option value="Goshen School District">Goshen School District</option><option value="Grant D. Morse Elementary School">Grant D. Morse Elementary School</option><option value="Greenwood Lake School District">Greenwood Lake School District</option><option value="Haldane School District">Haldane School District</option><option value="Highland Falls-Fort Montgomery School District">Highland Falls-Fort Montgomery School District</option><option value="Highland School District">Highland School District</option><option value="Hudson School District">Hudson School District</option><option value="Hyde Park School District">Hyde Park School District</option><option value="Kinderhook School District">Kinderhook School District</option><option value="Kingston School District">Kingston School District</option><option value="Kiryas Joel Village Union Free School District">Kiryas Joel Village Union Free School District</option><option value="Mahopac School District">Mahopac School District</option><option value="Marlboro School District">Marlboro School District</option><option value="Middletown School District">Middletown School District</option><option value="Millbrook School District">Millbrook School District</option><option value="Minisink Valley School District">Minisink Valley School District</option><option value="Monroe-Woodbury School District">Monroe-Woodbury School District</option><option value="New Lebanon School District">New Lebanon School District</option><option value="New Paltz School District">New Paltz School District</option><option value="Newburgh School District">Newburgh School District</option><option value="Northeast School District">Northeast School District</option><option value="Onteora School District">Onteora School District</option><option value="Pawling School District">Pawling School District</option><option value="Pine Bush School District">Pine Bush School District</option><option value="Pine Plains School District">Pine Plains School District</option><option value="Port Jervis School District">Port Jervis School District</option><option value="Poughkeepsie School District">Poughkeepsie School District</option><option value="Private School">Private School</option><option value="Putnam Valley School District">Putnam Valley School District</option><option value="Red Hook School District">Red Hook School District</option><option value="Rhinebeck School District">Rhinebeck School District</option><option value="Rondout Valley School District">Rondout Valley School District</option><option value="Saugerties School District">Saugerties School District</option><option value="Spackenkill School District">Spackenkill School District</option><option value="Taconic Hills Central School District">Taconic Hills Central School District</option><option value="Tuxedo School District">Tuxedo School District</option><option value="Ulster County">Ulster County</option><option value="Valley Central School District">Valley Central School District</option><option value="Wallkill School District">Wallkill School District</option><option value="Wappingers School District">Wappingers School District</option><option value="Warwick Valley School District">Warwick Valley School District</option><option value="Washingtonville School District">Washingtonville School District</option><option value="West Park School District">West Park School District</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Education"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Educational Level</label><select name="CST_59" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Pre-Kindergarten (Pre-K)">Pre-Kindergarten (Pre-K)</option><option value="Kindergarten (K)">Kindergarten (K)</option><option value="1st Grade">1st Grade</option><option value="2nd Grade">2nd Grade</option><option value="3rd Grade">3rd Grade</option><option value="4th Grade">4th Grade</option><option value="5th Grade">5th Grade</option><option value="6th Grade">6th Grade</option><option value="7th Grade">7th Grade</option><option value="8th Grade">8th Grade</option><option value="9th Grade (Freshman)">9th Grade (Freshman)</option><option value="10th Grade (Sophomore)">10th Grade (Sophomore)</option><option value="11th Grade (Junior)">11th Grade (Junior)</option><option value="12th Grade (Senior)">12th Grade (Senior)</option><option value="High School Diploma or GED">High School Diploma or GED</option><option value="Some College (no degree)">Some College (no degree)</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Requested Services & Additional Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the youth ever received Clinic services before?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="Unsure">Unsure</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_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></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 required">Family Preferences: (Male/Female staff, evening hours, etc.)</label><input name="CST_33" type="text" class="er_fld_required"></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 required">Any known Safety Concerns? (Criminal Record, History of Violence, Weapons in the Home, Sex Offender, General Concerns, etc.)</label><input name="CST_35" 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">Symptoms of Concern</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Alcohol use">Alcohol use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Anxiety">Anxiety</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Attention Deficits">Attention Deficits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Danger to others">Danger to others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Danger to self">Danger to self</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Depression">Depression</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Developmental delays">Developmental delays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Drug use">Drug use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Eating disturbances">Eating disturbances</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Enuresis/Encopresis">Enuresis/Encopresis</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Hyperactivity">Hyperactivity</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Impulsivity">Impulsivity</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Irritability">Irritability</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Mood Swings">Mood Swings</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Negative peer interactions">Negative peer interactions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Phobia">Phobia</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Physical complaints">Physical complaints</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Physically aggressive">Physically aggressive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Problematic social behavior">Problematic social behavior</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Runaway">Runaway</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="School Attendance Issues">School Attendance Issues</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Self-injury">Self-injury</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Sexually Aggressive">Sexually Aggressive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Sexually inappropriate">Sexually inappropriate</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Sleep disturbances">Sleep disturbances</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Suicidal Ideation">Suicidal Ideation</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Temper Tantrums">Temper Tantrums</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Verbally aggressive">Verbally aggressive</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_36" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_36_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Has the client recently been discharged from any of the following within the last 30 days: (select all that apply)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Hospital">Hospital</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Partial Hospitalization">Partial Hospitalization</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Residential Treatment Facility (RTF)">Residential Treatment Facility (RTF)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Crisis Residence (CR)">Crisis Residence (CR)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Children's Community Residence (CCR)">Children's Community Residence (CCR)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="Substance Use Treatment">Substance Use Treatment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_60" value="N/A">N/A</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_60" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_60_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Additional information for the counseling center</label><textarea name="CST_37" style="width:100%;" class="er_fld_required"></textarea></li></ul>
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