Online Referral
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<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">Community 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>Case Management 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">Referred By Name</label><input name="CST_1" 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">Referred By Cell/Emergency #</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">Referred By Email</label><input name="CST_2" 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">DHHS Agency</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="DCFS">DCFS</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="DJJYS">DJJYS</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_64" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_64_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" map_to="CC_ReferralSource_Ref" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=DCFS"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DCFS Region</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Eastern">Eastern</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Northern">Northern</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Salt Lake">Salt Lake</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Southwest">Southwest</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Western">Western</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank er_fld_required" type="radio" name="CST_65" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_65_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_ReferralSource_Ref" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=DJJYS"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DJJYS Office</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Cedar City (C9Y)">DJJS Cedar City (C9Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Richfield (C5Y)">DJJS Richfield (C5Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Logan (C2Y)">DJJS Logan (C2Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Ogden (A1Y)">DJJS Ogden (A1Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Orem (A5Y)">DJJS Orem (A5Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Price (C6Y)">DJJS Price (C6Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Salt Lake (A3Y)">DJJS Salt Lake (A3Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS St. George (C7Y)">DJJS St. George (C7Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Vernal (C4Y)">DJJS Vernal (C4Y)</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_9" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_9_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>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_10" 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_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">DOB</label><input class="cst_datepicker er_fld_required" name="CST_12" 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">Age</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" 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 er_fld_required" type="radio" name="CST_62" value="Female">Female</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_62" value="Male">Male</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_62" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_62_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_selected" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CustomField_Value_8"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender Identity</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Genderqueer">Genderqueer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Gender Non-Conforming">Gender Non-Conforming</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Intergender">Intergender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Intersex">Intersex</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Nonbinary">Nonbinary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Other">Other</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Transgender">Transgender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Trans Man/Male">Trans Man/Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Trans Woman/Female">Trans Woman/Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="I do not wish to provide this information">I do not wish to provide this information</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_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_Other" type="text"></label></li></ul><ul class="er_fld_row"><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_67" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown">Unknown</option><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Language"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Language</label><select name="CST_68" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Arabic">Arabic</option><option value="Bengali">Bengali</option><option value="Chinese">Chinese</option><option value="English">English</option><option value="French">French</option><option value="German">German</option><option value="Hindi">Hindi</option><option value="Japanese">Japanese</option><option value="Lahnda">Lahnda</option><option value="Marathi">Marathi</option><option value="Portuguese">Portuguese</option><option value="Russian">Russian</option><option value="Spanish">Spanish</option><option value="Tagalog">Tagalog</option><option value="Tamil">Tamil</option><option value="Turkish">Turkish</option><option value="Urdu">Urdu</option><option value="Vietnamese">Vietnamese</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;" map_to="CC_Religion"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Religion</label><select name="CST_69" class="er_fld_required er_fld_width50"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Buddhist">Buddhist</option><option value="Catholic">Catholic</option><option value="Christian">Christian</option><option value="Evangelical">Evangelical</option><option value="Hindu">Hindu</option><option value="Islam">Islam</option><option value="Jehovah Witness">Jehovah Witness</option><option value="Jewish">Jewish</option><option value="LDS">LDS</option><option value="Protestant">Protestant</option><option value="Declined">Declined</option><option value="None">None</option><option value="Other">Other</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security #</label><input name="CST_14" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_6"> <i class="fa fa-font"></i><label class="er_fld_label required">Case Number</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><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_16" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_7"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Anticipated Placement Date</label><input class="cst_datepicker er_fld_required" name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Parent/Guardian Information</label><hr></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">Parent/Guardian</label><input name="CST_18" 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">Relationship to Client</label><input name="CST_59" type="text" class=""></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">Phone</label><input name="CST_19" 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">Address</label><input name="CST_20" 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">Email</label><input name="CST_21" 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">Parent/Guardian</label><input name="CST_22" 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">Relationship to Client</label><input name="CST_60" 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">Phone</label><input name="CST_23" 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">Address</label><input name="CST_24" 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">Email</label><input name="CST_25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Services</label><hr></li></ul><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 er_fld_fontstyle_info">Mentoring Services (MT1) Mentoring services are provided by trained Live for Life Transition Coaches and are community-based. Mentoring services are designed to provide strength-based support in daily living and social situations, accessing community resources, and addressing communication needs to maximize youths’ successful living in the community. </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">After Care Services (NNC) Aftercare Services (NNC) provide support to families and clients when they discharge from a Qualified Residential Treatment Program and transition to a home setting. </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">Psychosocial Rehabilitation Services (PRS) Individual and group psychosocial rehabilitative services (PRS) are provided to youth in secure care (Decker Lake and Farmington Bay Youth Centers) to help prepare them as they transition out of secure care into the community. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Service Requested</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_66" value="Mentoring Services (MT1)">Mentoring Services (MT1)</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_66" value="After Care Services (NNC)">After Care Services (NNC)</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_66" value="Psychosocial Rehabilitation Service (PRS)">Psychosocial Rehabilitation Service (PRS)</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_66" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_66_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;" er_fld_condvals="er_fld_showif_values=Mentoring+Services+(MT1)&er_fld_showif_values=After+Care+Services+(NNC)"><i class="fa fa-header"></i><label>Concerns</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" er_fld_condvals="er_fld_showif_values=Mentoring+Services+(MT1)"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please Select All That Apply</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Psychiatric Issues">Psychiatric Issues</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Substance Use History">Substance Use History</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Family Issues">Family Issues</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Sexual Abuse History">Sexual Abuse History</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Assaultive History">Assaultive History</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Suicidal Ideation">Suicidal Ideation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Physical Abuse History">Physical Abuse History</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="AWOL Runaway">AWOL Runaway</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_56" value="Antisocial Peers">Antisocial Peers</label><label class="er_option er_option_other"><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_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=After+Care+Services+(NNC)"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Summary of Concerns</label><textarea name="CST_57" style="width:100%;" class="er_fld_blank"></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>Insurance 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_Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label">Medicaid #</label><input name="CST_26" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">MI 706 #</label><input name="CST_27" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Education</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Education"> <i class="fa fa-font"></i><label class="er_fld_label">Current Grade</label><input name="CST_52" type="text" class=""></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Credits</label><input name="CST_53" 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">Safe School Violations</label><input name="CST_54" type="text"></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">Enter content here...</div></li></ul>
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