Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><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"><img src="data:image/jpeg;base64,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"></div></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Referral Date:</label><input class="cst_datepicker er_fld_required" name="CST_1" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Category_Ref"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Program Category </label><select name="CST_92" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Preventive-Dutchess">Preventive-Dutchess</option><option value="Preventive-Orange">Preventive-Orange</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_selected" 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 - Preventive Services Referral</div></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>Case 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">First Name:</label><input name="CST_14" 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">Last Name:</label><input name="CST_15" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">D.O.B.:</label><input class="cst_datepicker er_fld_required" name="CST_82" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Gender"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender:</label><select name="CST_83" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option><option value="Prefer not to answer">Prefer not to answer</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Race"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_89" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="American Indian or Alaska Native">American Indian or Alaska Native</option><option value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</option><option value="Biracial">Biracial</option><option value="Asian">Asian</option><option value="Black or African American">Black or African American</option><option value="Caucasian/White">Caucasian/White</option><option value="Hispanic">Hispanic</option><option value="Multiracial">Multiracial</option></select></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_90" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false" map_to="CustomField_Value_7"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is this youth of Native American or Alaska Native Descent?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="Unknown">Unknown</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_80" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_80_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>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_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referral Source (Outside agency): </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_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referred By (CPS Caseworker/Supervisor):</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: 33.3333%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referrer's Phone #:</label><input name="CST_6" 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">Referrer's Email:</label><input name="CST_85" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_6"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Referring County:</label><select name="CST_91" 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><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_ReferralReason_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Type of Referral: </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_3" value="Community Referral">Community Referral</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_3" value="C.P.S. Mandated Referral (Protective)">C.P.S. Mandated Referral (Protective)</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_3" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_3_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_RefSecReason_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Level: </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_4" value="Level 1">Level 1</label><label class="er_option"><input class="type_radio" type="radio" name="CST_4" value="Level 2">Level 2</label><label class="er_option"><input class="type_radio" type="radio" name="CST_4" value="Level 3">Level 3</label><label class="er_option"><input class="type_radio" type="radio" name="CST_4" value="Level 4">Level 4</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_4" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_4_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>Legal Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Court-Ordered Services:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_7" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_7" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_7" value="Petition Pending">Petition Pending</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_7" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_7_Other" type="text"></label></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_7" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Petition+Pending"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Copy of Order will need to be provided. </div></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_7" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Petition+Pending"> <i class="fa fa-font"></i><label class="er_fld_label required">Judge:</label><input name="CST_8" 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_7" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Petition+Pending"> <i class="fa fa-font"></i><label class="er_fld_label required">DCFS Attorney:</label><input name="CST_9" 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_7" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Petition+Pending"> <i class="fa fa-font"></i><label class="er_fld_label required">Attorney for child:</label><input name="CST_10" 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%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Petition+Pending"> <i class="fa fa-font"></i><label class="er_fld_label required">Client’s Attorney (s):</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_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Orders of Protection:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Pending">Pending</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></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Pending"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Copy of Order will need to be provided. </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>Household Composition</label><hr></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 required">1. Name:</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">D.O.B.</label><input class="cst_datepicker er_fld_required" name="CST_16" 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 required">Relationship to Child(ren) (primary):</label><input name="CST_17" type="text" value="" 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">2. Name:</label><input name="CST_18" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">D.O.B.</label><input class="cst_datepicker er_fld_required" name="CST_21" 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 required">Relationship to Child(ren) (Non-primary):</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: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">3. Name:</label><input name="CST_22" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">D.O.B.</label><input class="cst_datepicker" name="CST_23" 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">Relationship to Child(ren):</label><input name="CST_24" 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">4. Name:</label><input name="CST_25" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">D.O.B.</label><input class="cst_datepicker" name="CST_26" 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 to Child(ren):</label><input name="CST_27" 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">5. Name:</label><input name="CST_28" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">D.O.B.</label><input class="cst_datepicker" name="CST_29" 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">Relationship to Child(ren):</label><input name="CST_30" 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">6. Name:</label><input name="CST_31" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">D.O.B.</label><input class="cst_datepicker" name="CST_32" 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">Relationship to Child(ren):</label><input name="CST_33" 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_normal"></div></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">Primary Case Address (where children reside):</label><input name="CST_35" type="text" class="er_fld_required"></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_36" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State:</label><input name="CST_37" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;" map_to="CC_Address_Zip"> <i class="fa fa-hashtag"></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_81" 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_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_normal">Primary Caretaker Phone Numbers</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label">Home Phone:</label><input name="CST_39" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Work"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone:</label><input name="CST_40" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label">Cell (Mobile):</label><input name="CST_41" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Non-Custodial/Non-Primary Address:</label><textarea name="CST_42" style="width:100%;">Address: City: State: Zip: County:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Non-Custodial/Non-Primary Phone Numbers:</label><textarea name="CST_44" style="width:100%;">Home Phone: Work Phone: Cell/Mobile:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Referral Details</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Problems Precipitating Referral:</label><textarea name="CST_45" style="width:100%;" class="er_fld_required"></textarea></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">Special Conditions: (Check any that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Active drugs/Alcohol suspected">Active drugs/Alcohol suspected</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Drug screens requested">Drug screens requested</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Domestic Violence">Domestic Violence</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Medical Neglect">Medical Neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Educational Neglect">Educational Neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Serious problems of children">Serious problems of children</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Spanish-speaking">Spanish-speaking</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Unsanitary/Unsafe living conditions">Unsanitary/Unsafe living conditions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Eviction Pending/Family in homeless shelter">Eviction Pending/Family in homeless shelter</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Serious Mental Health Issues">Serious Mental Health Issues</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Teen or limited parent">Teen or limited parent</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="Child(ren) are to be in day care">Child(ren) are to be in day care</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_46_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 er_fld_fontstyle_info">Goals which must be met for case to be closed (identify client and include line number from page 1) This must be completed to accept the 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%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">1.</label><textarea name="CST_47" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">2.</label><textarea name="CST_48" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">3.</label><textarea name="CST_49" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">4.</label><textarea name="CST_50" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">5.</label><textarea name="CST_51" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">6.</label><textarea name="CST_52" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">7.</label><textarea name="CST_53" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style=""> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Current Service Providers/Agency: (i.e. Mental Health, RISC, DAAC, Substance Abuse) If there are no other service providers, write “N/A” in the first field</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">1. Service Provider:</label><input name="CST_55" 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">Contact Person (if known):</label><input name="CST_56" 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">Phone No.:</label><input name="CST_57" 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">2. Service Provider:</label><input name="CST_58" 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">Contact Person (if known):</label><input name="CST_59" 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">Phone No.:</label><input name="CST_60" 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">3. Service Provider:</label><input name="CST_61" 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">Contact Person (if known):</label><input name="CST_62" 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">Phone No.:</label><input name="CST_63" 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">4. Service Provider:</label><input name="CST_64" 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">Contact Person (if known):</label><input name="CST_65" 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">Phone No.:</label><input name="CST_66" 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">5. Service Provider:</label><input name="CST_67" 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">Contact Person (if known):</label><input name="CST_68" 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">Phone No.:</label><input name="CST_69" 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">6. Service Provider:</label><input name="CST_70" 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">Contact Person (if known):</label><input name="CST_71" 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">Phone No.:</label><input name="CST_72" type="text"></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">Miscellaneous Information:</label><textarea name="CST_73" style="width:100%;"></textarea></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>Services Required</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">SNAP (FS)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_74" value="Pending">Pending</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_74" value="Other:">Other:<input class="cst_Other" name="CST_74_Other" type="text"></label></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_74" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Pending"> <i class="fa fa-calendar"></i><label class="er_fld_label">Expiration Date:</label><input class="cst_datepicker" name="CST_75" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">MA</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="Pending">Pending</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_76" value="Other:">Other:<input class="cst_Other" name="CST_76_Other" type="text"></label></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Pending"> <i class="fa fa-calendar"></i><label class="er_fld_label">Expiration Date:</label><input class="cst_datepicker" name="CST_77" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">TA</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_78" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_78" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_78" value="Pending">Pending</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_78" value="Other:">Other:<input class="cst_Other" name="CST_78_Other" type="text"></label></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_78" er_fld_condvals="er_fld_showif_values=Yes&er_fld_showif_values=Pending"> <i class="fa fa-calendar"></i><label class="er_fld_label">Expiration Date:</label><input class="cst_datepicker" name="CST_79" type="text"></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_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">After reviewing the information above for accuracy, please click SUBMIT to process this referral.</div></li></ul>
Submit