Online Referral
Please attach a hard copy of this form below, or reenable the web form.
<ul class="er_fld_row"><li class="er_fld_type_date" draggable="false"><i class="fa fa-calendar"></i><label class="er_fld_label required">Date</label><input class="cst_datepicker er_fld_width25 er_fld_required" name="CST_1" type="text" value="1/23/2020"></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>Demographics</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_First"><i class="fa fa-font"></i><label class="er_fld_label required">Client First Name</label><input name="CST_6" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_Last"><i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name</label><input name="CST_7" type="text" class="er_fld_required" value=""></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">Parent/Guardian 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%;"><i class="fa fa-font"></i><label class="er_fld_label required">Relationship</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%;" map_to="CC_Address_Street_1"><i class="fa fa-font"></i><label class="er_fld_label required">Address</label><input name="CST_4" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_County"><i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_5" type="text" class="er_fld_required" value=""></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">City</label><input name="CST_8" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_State"><i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_9" type="text" value="Florida" 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">Zip</label><input name="CST_10" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Home"><i class="fa fa-font"></i><label class="er_fld_label required">Home Phone</label><input name="CST_11" type="text" class="er_fld_required" value=""></li><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">Cell Phone</label><input name="CST_12" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Work"><i class="fa fa-font"></i><label class="er_fld_label">Work Phone</label><input name="CST_13" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="" map_to="CC_EMail"><i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_14" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 25%;" map_to="CC_Gender"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_15" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option><option value="Transgender">Transgender</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_16" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Asian ">Asian </option><option value="Black ">Black </option><option value="Hispanic ">Hispanic </option><option value="White">White</option><option value="Multiracial ">Multiracial </option></select></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">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_17" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label required">Age</label><input name="CST_18" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CustomField_Value_1"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Legal Status</label><select name="CST_19" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Minor in custody of parent/guardian ">Minor in custody of parent/guardian </option><option value="Minor in State Custody ">Minor in State Custody </option><option value="Adult ">Adult </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_State"><i class="fa fa-font"></i><label class="er_fld_label required">School</label><input name="CST_20" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Employer"><i class="fa fa-font"></i><label class="er_fld_label required">Employer</label><input name="CST_21" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><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 of Client</label><input name="CST_22" type="text" class="er_fld_required" value=""></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">Primary Language of Parent/Legal Guardian</label><input name="CST_23" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Services Needed / Description of Problems</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Services Needed</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_24" value="Lifeskills Group ">Lifeskills Group </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_24" value="Supportive Services for Children of Incarcerated Parents">Supportive Services for Children of Incarcerated Parents</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_24" value="Parenting Class ">Parenting Class </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_24" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_24_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space:normal;" draggable="false" map_to="CustomField_Value_2"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please check all current problems or symptoms:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Anxiety ">Anxiety </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Grief/Loss ">Grief/Loss </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="School Problems">School Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Anger Problems ">Anger Problems </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Parenting Issue ">Parenting Issue </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Life Transition Issue">Life Transition Issue</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="ADHD ">ADHD </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Communication Issues ">Communication Issues </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Problems at Work">Problems at Work</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Depression ">Depression </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Family Conflict ">Family Conflict </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Problems with Attention/Concentration">Problems with Attention/Concentration</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Disruptive Behavior ">Disruptive Behavior </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Low Self-Esteem ">Low Self-Esteem </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Relationship Issue">Relationship Issue</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></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">Comments</label><textarea name="CST_26" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style=""><i class="fa fa-header"></i><label>Referral Source (If other than Client or Parent/Guardian)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style=""><i class="fa fa-font"></i><label class="er_fld_label">Referring Agency or School</label><input name="CST_27" type="text"></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">Name of Person Completing Form</label><input name="CST_28" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Title of Person Completing Form</label><input name="CST_29" 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">Phone</label><input name="CST_30" 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">Fax</label><input name="CST_31" 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">Email</label><input name="CST_32" type="text"></li></ul>
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