Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"><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: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Live for Life Sequoia Live for Life Sequoia, located in West Jordan City, provides a variety of services to give clients many mediums through which they can learn. Specifically, we provide mental health assessments, individual, family, and group therapy, as well as psychiatric assessments and medication management, which are performed by our highly trained clinicians and APRNs. Additionally, its various components match well with the What Works Principles, ensuring that its delivery is effective at promoting change. We utilize a variety of interventions to ensure that treatment is individualized while also being in line with evidence-based practices.</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">Case Manager 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">Case Manager Cell/Emergency #</label><input name="CST_4" type="text" class="er_fld_required er_fld_width100"></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">Case Manager 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" type="radio" name="CST_63" value="DCFS">DCFS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" 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_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_radio er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=DCFS" map_to="CC_ReferralSource_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DCFS Region</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_64" value="Eastern">Eastern</label><label class="er_option"><input class="type_radio" type="radio" name="CST_64" value="Northern">Northern</label><label class="er_option"><input class="type_radio" type="radio" name="CST_64" value="Salt Lake">Salt Lake</label><label class="er_option"><input class="type_radio" type="radio" name="CST_64" value="Southwest">Southwest</label><label class="er_option"><input class="type_radio" type="radio" name="CST_64" value="Western">Western</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_64" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_64_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_63" 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" type="radio" name="CST_9" value="DJJS Cedar City (C9Y)">DJJS Cedar City (C9Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Richfield (C5Y)">DJJS Richfield (C5Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Logan (C2Y)">DJJS Logan (C2Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Ogden (A1Y)">DJJS Ogden (A1Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Orem (A5Y)">DJJS Orem (A5Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Price (C6Y)">DJJS Price (C6Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS Salt Lake (A3Y)">DJJS Salt Lake (A3Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_9" value="DJJS St. George (C7Y)">DJJS St. George (C7Y)</label><label class="er_option"><input class="type_radio" 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_68" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="Female">Female</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_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_Other" type="text"></label></li><li class="er_fld_type_radio" 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_67" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Genderqueer">Genderqueer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Gender Non-Conforming">Gender Non-Conforming</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Intergender">Intergender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Intersex">Intersex</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Nonbinary">Nonbinary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Other">Other</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Transgender">Transgender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Trans Man/Male">Trans Man/Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Trans Woman/Female">Trans Woman/Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" 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_67" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_67_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_69" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown" selected="">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_70" 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" selected="">English</option><option value="French">French</option><option value="German">German</option><option value="Hindi">Hindi</option><option value="Japanese">Japanese</option><option value="Karen">Karen</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="Swahili">Swahili</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 er_fld_selected" 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_71" class="er_fld_width50 er_fld_required"><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" selected="">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: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent/Guardian Name</label><input name="CST_18" type="text" class="er_fld_width50 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">Relationship to Client</label><select name="CST_77" class="er_fld_width50 er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Guardian - Aunt">Guardian - Aunt</option><option value="Guardian - Father">Guardian - Father</option><option value="Guardian - Grandfather">Guardian - Grandfather</option><option value="Guardian - Grandmother">Guardian - Grandmother</option><option value="Guardian - Mother">Guardian - Mother</option><option value="Guardian - Other">Guardian - Other</option><option value="Guardian - Step-Father">Guardian - Step-Father</option><option value="Guardian - Step-Mother">Guardian - Step-Mother</option><option value="Guardian - Uncle">Guardian - Uncle</option><option value="Guardian Ad-Litem">Guardian Ad-Litem</option><option value="Non-Guardian - Aunt">Non-Guardian - Aunt</option><option value="Non-Guardian - Father">Non-Guardian - Father</option><option value="Non-Guardian - Grandfather">Non-Guardian - Grandfather</option><option value="Non-Guardian - Grandmother">Non-Guardian - Grandmother</option><option value="Non-Guardian - Mother">Non-Guardian - Mother</option><option value="Non-Guardian - Other">Non-Guardian - Other</option><option value="Non-Guardian - Step-Father">Non-Guardian - Step-Father</option><option value="Non-Guardian - Step-Mother">Non-Guardian - Step-Mother</option><option value="Non-Guardian - Uncle">Non-Guardian - Uncle</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other Relative">Other Relative</option><option value=""></option><option value=""></option></select></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">Are There Any Contact Restrictions</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_79" value="Restricted - Supervised Visits Only">Restricted - Supervised Visits Only</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_79" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_79_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Emergency Contact?</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 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_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone</label><input name="CST_19" type="text" class="er_fld_width25 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">Address</label><input name="CST_20" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_21" type="text" class="er_fld_width50 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">Parent/Guardian Name</label><input name="CST_22" type="text" class="er_fld_width50"></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">Relationship to Client</label><select name="CST_81" class="er_fld_width50"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Guardian - Aunt">Guardian - Aunt</option><option value="Guardian - Father">Guardian - Father</option><option value="Guardian - Grandfather">Guardian - Grandfather</option><option value="Guardian - Grandmother">Guardian - Grandmother</option><option value="Guardian - Mother">Guardian - Mother</option><option value="Guardian - Other">Guardian - Other</option><option value="Guardian - Step-Father">Guardian - Step-Father</option><option value="Guardian - Step-Mother">Guardian - Step-Mother</option><option value="Guardian - Uncle">Guardian - Uncle</option><option value="Guardian Ad-Litem">Guardian Ad-Litem</option><option value="Non-Guardian - Aunt">Non-Guardian - Aunt</option><option value="Non-Guardian - Father">Non-Guardian - Father</option><option value="Non-Guardian - Grandfather">Non-Guardian - Grandfather</option><option value="Non-Guardian - Grandmother">Non-Guardian - Grandmother</option><option value="Non-Guardian - Mother">Non-Guardian - Mother</option><option value="Non-Guardian - Other">Non-Guardian - Other</option><option value="Non-Guardian - Step-Father">Non-Guardian - Step-Father</option><option value="Non-Guardian - Step-Mother">Non-Guardian - Step-Mother</option><option value="Non-Guardian - Uncle">Non-Guardian - Uncle</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other Relative">Other Relative</option><option value=""></option><option value=""></option></select></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">Are There Any Contact Restriction?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_83" value="Restricted - Supervised Visits Only">Restricted - Supervised Visits Only</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_83" value="Other:">Other:<input class="cst_Other" name="CST_83_Other" type="text"></label></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">Emergency Contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_84" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_84" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_84" value="Other:">Other:<input class="cst_Other" name="CST_84_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">Phone</label><input name="CST_23" type="text" class="er_fld_width25"></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" class="er_fld_width50"></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>Additional Contacts</label><hr></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">Contact Name</label><input name="CST_85" type="text" class="er_fld_width50"></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">Relationship to Client</label><select name="CST_86" class="er_fld_width50"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Guardian - Aunt">Guardian - Aunt</option><option value="Guardian - Father">Guardian - Father</option><option value="Guardian - Grandfather">Guardian - Grandfather</option><option value="Guardian - Grandmother">Guardian - Grandmother</option><option value="Guardian - Mother">Guardian - Mother</option><option value="Guardian - Other">Guardian - Other</option><option value="Guardian - Step-Father">Guardian - Step-Father</option><option value="Guardian - Step-Mother">Guardian - Step-Mother</option><option value="Guardian - Uncle">Guardian - Uncle</option><option value="Guardian Ad-Litem">Guardian Ad-Litem</option><option value="Non-Guardian - Aunt">Non-Guardian - Aunt</option><option value="Non-Guardian - Father">Non-Guardian - Father</option><option value="Non-Guardian - Grandfather">Non-Guardian - Grandfather</option><option value="Non-Guardian - Grandmother">Non-Guardian - Grandmother</option><option value="Non-Guardian - Mother">Non-Guardian - Mother</option><option value="Non-Guardian - Other">Non-Guardian - Other</option><option value="Non-Guardian - Step-Father">Non-Guardian - Step-Father</option><option value="Non-Guardian - Step-Mother">Non-Guardian - Step-Mother</option><option value="Non-Guardian - Uncle">Non-Guardian - Uncle</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other Relative">Other Relative</option></select></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">Are There Any Contact Restriction?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_88" value="Restricted - Supervised Visits Only">Restricted - Supervised Visits Only</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_88" value="Other:">Other:<input class="cst_Other" name="CST_88_Other" type="text"></label></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">Emergency Contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_89" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_89" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_89" value="Other:">Other:<input class="cst_Other" name="CST_89_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">Phone</label><input name="CST_90" type="text" class="er_fld_width25"></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_91" 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_92" type="text" class="er_fld_width50"></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">Contact Name</label><input name="CST_93" type="text" class="er_fld_width50"></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">Relationship to Client</label><select name="CST_94" class="er_fld_width50"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Guardian - Aunt">Guardian - Aunt</option><option value="Guardian - Father">Guardian - Father</option><option value="Guardian - Grandfather">Guardian - Grandfather</option><option value="Guardian - Grandmother">Guardian - Grandmother</option><option value="Guardian - Mother">Guardian - Mother</option><option value="Guardian - Other">Guardian - Other</option><option value="Guardian - Step-Father">Guardian - Step-Father</option><option value="Guardian - Step-Mother">Guardian - Step-Mother</option><option value="Guardian - Uncle">Guardian - Uncle</option><option value="Guardian Ad-Litem">Guardian Ad-Litem</option><option value="Non-Guardian - Aunt">Non-Guardian - Aunt</option><option value="Non-Guardian - Father">Non-Guardian - Father</option><option value="Non-Guardian - Grandfather">Non-Guardian - Grandfather</option><option value="Non-Guardian - Grandmother">Non-Guardian - Grandmother</option><option value="Non-Guardian - Mother">Non-Guardian - Mother</option><option value="Non-Guardian - Other">Non-Guardian - Other</option><option value="Non-Guardian - Step-Father">Non-Guardian - Step-Father</option><option value="Non-Guardian - Step-Mother">Non-Guardian - Step-Mother</option><option value="Non-Guardian - Uncle">Non-Guardian - Uncle</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other Relative">Other Relative</option></select></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">Are There Any Contact Restriction?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_96" value="Restricted - Supervised Visits Only">Restricted - Supervised Visits Only</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_96" value="Other:">Other:<input class="cst_Other" name="CST_96_Other" type="text"></label></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">Emergency Contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_97" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_97" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_97" value="Other:">Other:<input class="cst_Other" name="CST_97_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">Phone</label><input name="CST_98" type="text" class="er_fld_width25"></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_99" type="text"></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">Email</label><input name="CST_100" type="text" class="er_fld_width50"></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>Treatment Information</label><hr></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">Treatment History</label><textarea name="CST_31" style="width:100%;" class="er_fld_required"></textarea></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">Treatment Needs</label><textarea name="CST_32" style="width:100%;" class="er_fld_required"></textarea></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">Concerns</label><textarea name="CST_57" style="width:100%;" class="er_fld_required"></textarea></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=Yes"><i class="fa fa-header"></i><label>Medication</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio sortable-chosen" style="white-space: normal; width: 50%;" draggable="true"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is The Client On Medication?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" 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_65" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_65_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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_33" type="text" class="er_fld_blank er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_35" type="text" class="er_fld_blank er_fld_width50"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_37" type="text" class="er_fld_blank er_fld_width50"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_39" type="text" class="er_fld_blank er_fld_width50"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_41" type="text" class="er_fld_width50"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_43" type="text" class="er_fld_width50 er_fld_blank"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_45" type="text" class="er_fld_width50 er_fld_blank"></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_65" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medication Name</label><input name="CST_47" type="text" class="er_fld_width50 er_fld_blank"></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>Medical Needs</label><hr></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"></label><textarea name="CST_49" style="width:100%;" class=""></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>Dental Needs</label><hr></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"></label><textarea name="CST_50" 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>Vision Needs</label><hr></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"></label><textarea name="CST_51" 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>Education</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;" map_to="CC_Education_B"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Current Grade</label><input name="CST_74" type="text" class="er_fld_width50"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Credits</label><input name="CST_75" type="text" class="er_fld_width50"></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">Safe School Violations</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_66" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_66" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other" name="CST_66_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: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">School Comments</label><textarea name="CST_76" style="width:100%;"></textarea></li></ul>
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