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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 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"></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 - Community Based Services Wendy's Wonderful Kids (WWK) Referral Form</div></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>Referral Source Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referral Source Name:</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%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number:</label><input name="CST_8" 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_9" 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>Youth Information</label><hr></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_bold">Each WWK youth referred must be documented. This form collects the information needed to create a child’s profile in the WWK database. It is able to be edited. Some questions may only relate to youth in the U.S. foster care system.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's First Name (Full):</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's Last Name (Initial Only):</label><input name="CST_10" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_DOB"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's Date of Birth:</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected er_fld_type_radio_col1" style="white-space: normal; width: 25%;" 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_12" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" 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_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 25%;" 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 er_fld_required" type="radio" name="CST_13" value="American Indian or Alaska Native">American Indian or Alaska Native</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_13" value="Asian">Asian</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_13" value="Black or African American">Black or African American</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_13" value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_13" value="Caucasian/White">Caucasian/White</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_13" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_13_Other" type="text"></label></li><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 the Child Hispanic?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_14" 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_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" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Date Youth Was Referred to the WWK Program:</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: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Placement:</label><input name="CST_4" 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_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Placement Address 1:</label><input name="CST_5" 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">Current Placement Address 2:</label><input name="CST_15" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Placement City:</label><input name="CST_16" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Placement Zip:</label><input name="CST_17" 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">What County is this Youth in Care of?</label><input name="CST_18" 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">Current Caseworker/Foster Parent at Their Placement Name:</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Caseworker/Foster Parent at Their Placement Phone Number:</label><input name="CST_19" 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_Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's Medical CIN Number:</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of Child's County Worker:</label><input name="CST_20" 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">County Worker's Phone Number:</label><input name="CST_21" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">County Worker's Email Address</label><input name="CST_22" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">How many times has the Child been removed/transitioned from a home/placement?</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"> <i class="fa fa-font"></i><label class="er_fld_label required">When did the most current removal take place?</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"> <i class="fa fa-font"></i><label class="er_fld_label required">When did the first removal take place?</label><input name="CST_25" type="text" class="er_fld_required"></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">Have the parental rights been terminated?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_27" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_27" 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_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Date(s) of termination of parental rights:</label><input name="CST_30" 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;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Reason(s) for entering the court system (Check all that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Neglect">Neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Medical neglect">Medical neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Domestic violence">Domestic violence</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Psychological or emotional abuse">Psychological or emotional abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Unable to care for child">Unable to care for child</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Physical abuse">Physical abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Abandonment">Abandonment</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Failure to return">Failure to return</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Caretaker’s alcohol use">Caretaker’s alcohol use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Caretaker’s drug use">Caretaker’s drug use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Child alcohol use">Child alcohol use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Child drug use">Child drug use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Prenatal alcohol exposure">Prenatal alcohol exposure</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Prenatal drug exposure">Prenatal drug exposure</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Diagnosed condition">Diagnosed condition</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Inadequate access to mental health services">Inadequate access to mental health services</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Inadequate access to medical services">Inadequate access to medical services</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Child behavior problem">Child behavior problem</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Death of caretaker">Death of caretaker</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Incarceration of caretaker">Incarceration of caretaker</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Caretaker’s significant impairment – physical or emotional">Caretaker’s significant impairment – physical or emotional</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Caretaker’s significant impairment – cognitive">Caretaker’s significant impairment – cognitive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Inadequate housing">Inadequate housing</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Child requested placement">Child requested placement</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Sex trafficking">Sex trafficking</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Parental immigration detainment or deportation">Parental immigration detainment or deportation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Family conflict related to child’s sexual orientation, gender identity, or gender expression">Family conflict related to child’s sexual orientation, gender identity, or gender expression</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Educational neglect">Educational neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Public agency title IV-E agreement">Public agency title IV-E agreement</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Homelessness">Homelessness</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Sexual abuse">Sexual abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Voluntary relinquishment for adoption">Voluntary relinquishment for adoption</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Runaway">Runaway</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Whereabouts unknown">Whereabouts unknown</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Cannot disclose">Cannot disclose</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_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"> <i class="fa fa-font"></i><label class="er_fld_label required">Number of placements betwen the most recent removal and the time the child entered WWK program (please provide activity log)::</label><input name="CST_32" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Where does the child reside at the time of this referral?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Family Foster (Relative)">Family Foster (Relative)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Family Foster (Non-Relative)">Family Foster (Non-Relative)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Runaway">Runaway</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Trial Home Visit">Trial Home Visit</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Institution">Institution</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Supervised Independent Living">Supervised Independent Living</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Group Home">Group Home</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Hospital">Hospital</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_33" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_33_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space:normal;" draggable="false" er_fld_condfld="CST_33" er_fld_condvals="er_fld_showif_values=Family+Foster+(Relative)&er_fld_showif_values=Family+Foster+(Non-Relative)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If in a foster home, was the child placed there directly by a public agency, or through a private agency?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_34" value="Public">Public</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_34" value="Private">Private</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_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_text er_fld_showif" draggable="false" er_fld_condfld="CST_33" er_fld_condvals="er_fld_showif_values=Family+Foster+(Relative)&er_fld_showif_values=Family+Foster+(Non-Relative)"> <i class="fa fa-font"></i><label class="er_fld_label required">If the youth is in a foster home, what agency oversees the home?</label><input name="CST_35" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_33" er_fld_condvals="er_fld_showif_values=Family+Foster+(Relative)&er_fld_showif_values=Family+Foster+(Non-Relative)"> <i class="fa fa-font"></i><label class="er_fld_label required">Who from the above agency can the WWK Recruiter contact? (Please provide name and phone number)</label><input name="CST_36" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">What was the monthly or daily payment that the public child welfare agency provided the placement on behalf of this child at the time the child entered the WWK program? (Please note if it was monthly or daily payments)</label><input name="CST_37" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Was the child eligible for title IV-E foster care at the time the child entered the WWK program?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" 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_38" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_38_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;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does the child have any physical, behavioral or mental health conditions?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Intellectual Disability">Intellectual Disability</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Autism Spectrum Disorder">Autism Spectrum Disorder</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Visual Impairment and Blindness">Visual Impairment and Blindness</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Hearing Impairment and Deafness">Hearing Impairment and Deafness</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Orthopedic Impairment or Other Physical Condition">Orthopedic Impairment or Other Physical Condition</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Mental or Emotional Disorders">Mental or Emotional Disorders</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Attention Deficit Hyperactivity Disorder">Attention Deficit Hyperactivity Disorder</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Serious Mental Disorders">Serious Mental Disorders</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Developmental Delay">Developmental Delay</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="Developmental Disabilities">Developmental Disabilities</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_39" value="No Disabilities">No Disabilities</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_39" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_39_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the child take any medication for the conditions checked off above?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" 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_41" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_41_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the child had a failed adoption that occurred pre-finalization prior to coming on the WWK caseload?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" value="Yes, pre-finalized">Yes, pre-finalized</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" value="Yes, post-finalized">Yes, post-finalized</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" value="Don't know">Don't know</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_42" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_42_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space:normal;" draggable="false" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes%2C+pre-finalized&er_fld_showif_values=Yes%2C+post-finalized"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If yes, was the previous adoption through the WWK program?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_43" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_43" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_43" value="Don't Know">Don't Know</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_43" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_43_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Characterize past efforts to recruit for this child (check all that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="No Past Efforts">No Past Efforts</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Minimal - General/Targeted">Minimal - General/Targeted</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Minimal - Child-specific">Minimal - Child-specific</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Extensive - General/Targeted">Extensive - General/Targeted</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Extensive - Child-specific">Extensive - Child-specific</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_44" value="Don't Know">Don't Know</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_44" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_44_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does the child have any siblings?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_45" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_45" value="No">No</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_45" value="Don't Know">Don't Know</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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label></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">Please complete for each sibling:</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">Sibling Name:</label><input name="CST_46" 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">Custodial Agency Case ID Number if still in care:</label><input name="CST_50" 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">Is this sibling in the WWK Program?</label><input name="CST_54" 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">Does this sibling live with the referred child?</label><input name="CST_58" type="text"></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">Sibling Name:</label><input name="CST_47" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Custodial Agency Case ID Number if still in care:</label><input name="CST_51" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Is this sibling in the WWK Program?</label><input name="CST_55" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Does this sibling live with the referred child?</label><input name="CST_59" type="text"></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">Sibling Name:</label><input name="CST_48" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Custodial Agency Case ID Number if still in care:</label><input name="CST_52" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Is this sibling in the WWK Program?</label><input name="CST_56" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Does this sibling live with the referred child?</label><input name="CST_60" type="text"></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">Sibling Name:</label><input name="CST_49" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Custodial Agency Case ID Number if still in care:</label><input name="CST_53" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Is this sibling in the WWK Program?</label><input name="CST_57" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Does this sibling live with the referred child?</label><input name="CST_61" 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">Additional information you feel will be helpful for the WWK Recruiter:</label><textarea name="CST_62" 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">Please include the following documentation with completed referral: ◻ Activity Movement Sheet ◻ School Information w/ IEP/504 plan ◻ Mental Health Diagnosis ◻ Medication List </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_bold">I hereby attest that the youth named above if not already will have a permanency plan of adoption, guardianship, kingap, and/or kinship once the TPR is finalized:</div></li></ul><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</label><input class="cst_datepicker" name="CST_65" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_63" type="text"><button class="type_button" disabled="">Clear Signature</button></li></ul>
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