Online Referral

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: 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: 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
Children and Family Treatment and Support Services (CFTSS) Referral Form</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>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: 33.3333%;" 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: 33.3333%;" 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></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 50%;">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_10" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" 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_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" 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_text" draggable="false" style="width: 25%;" map_to="CC_Address_County">
<i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_13" type="text" class="er_fld_required"></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" draggable="false" style="width: 33.3333%;">
		<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" draggable="false" style="width: 33.3333%;">
		<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" draggable="false" style="width: 25%;">
<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" draggable="false" style="width: 25%;">
		<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&amp;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" draggable="false" style="width: 50%;" map_to="CC_EMail">
<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" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile">
<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" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Caregiver Alternate Phone Number</label><input name="CST_18" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" 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><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_dropdown" draggable="false" style="width: 50%;">
<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></select></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_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_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 &amp; ICD 10 Code</label><input name="CST_23" 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_47" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Secondary Diagnosis &amp; ICD 10 Code</label><input name="CST_24" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Please note, proof of the client's diagnosis is required within 30 days of placing the referral. After 30 days, the referral will be closed and a new referral must be placed.</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 required">What school is the youth currently attending?</label><input name="CST_25" 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">What is the school district?</label><input name="CST_26" 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_6"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the youth currently in foster care or has the youth previously been in a foster care program?</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></ul><ul class="er_fld_row"><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">If the youth is currently in foster care, please provide the youth's county worker's name and the county worker's contact information</label><input name="CST_29" type="text" class="er_fld_required"></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 &amp; 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 CFTSS 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_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes&amp;er_fld_showif_values=No&amp;er_fld_showif_values=Unsure">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a completed OLP Evaluation/Medical Necessity form?</label><select name="CST_49" 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_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Please note, a completed OLP Evaluation/Medical Necessity form is required within 30 days of placing the referral. After 30 days, the referral will be closed and a new referral must be placed.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=No&amp;er_fld_showif_values=Unsure">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">The Children's Home of Poughkeepsie CFTSS program will complete an OLP Evaluation for Medical Necessity upon acceptance to the program if the youth does not have a completed form.</div></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">Referred CFTSS Service(s)</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Other Licensed Practitioner (OLP)">Other Licensed Practitioner (OLP)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Family Functional Therapy (FFT) (Available for families with youth aged 11-18 years old)">Family Functional Therapy (FFT) (Available for families with youth aged 11-18 years old)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Psychosocial Rehabilitation (PSR)">Psychosocial Rehabilitation (PSR)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Community Psychiatric Supports and Treatment (CPST)">Community Psychiatric Supports and Treatment (CPST)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Family Peer Support Service (FPSS)">Family Peer Support Service (FPSS)</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_30" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_30_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Preferred Service Location(s)</label>
		
   		
   		
   		
   <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Virtual">Virtual</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="In Person">In Person</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Hybrid">Hybrid</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Home">Home</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="School">School</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Community">Community</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_56" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_56_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 identified Service Restrictions Surrounding Client Availability</label><input name="CST_34" 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 er_fld_required" type="checkbox" name="CST_36" value="Depression">Depression</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Temper Tantrums">Temper Tantrums</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Developmental delays">Developmental delays</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Physically aggressive">Physically aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Self-injury">Self-injury</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Anxiety">Anxiety</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Sleep disturbances">Sleep disturbances</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Sexually inappropriate">Sexually inappropriate</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Eating disturbances">Eating disturbances</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Runaway">Runaway</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Phobia">Phobia</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Enuresis/Encopresis">Enuresis/Encopresis</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Sexually Aggressive">Sexually Aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Negative peer interactions">Negative peer interactions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Delinquent Behavior">Delinquent Behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Danger to self">Danger to self</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Physically complaints">Physically complaints</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Verbally aggressive">Verbally aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Hyperactive">Hyperactive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Problematic social behavior">Problematic social behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Danger to others">Danger to others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Alcohol use">Alcohol use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Drug use">Drug use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Impulsive">Impulsive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Attention Deficits">Attention Deficits</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_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Additional background information for the CFTSS provider</label><textarea name="CST_37" 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 note that the following documentation must be provided upon completion of the CFTSS referral form:

- Proof of Mental Health Diagnosis
- Medical Necessity Form

Please send supporting documentation or questions to melliott@childrenshome.us, thank you!</div></li></ul>