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 Aspen Live for Life Aspen Live for Life Aspen, located in Murray City, provides transition services in a residential setting that helps teens and young adults ages 16-21 reduce recidivism by helping them successfully reintegrate into the community following placement from a higher level of care. </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 er_fld_selected" 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" 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 -">- Not Specified -</option><option value="Buddhist" selected="">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: 100%;"><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_78" 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" er_fld_condvals="er_fld_showif_values=Yes"><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 er_fld_required" type="checkbox" name="CST_82" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_82" 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_82" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_82_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_83" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_83" 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_83" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_83_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: 50%;"> <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_79" 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 Restrictions?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_89" 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_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_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_91" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_91" 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_91" value="Other:">Other:<input class="cst_Other" name="CST_91_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_84" 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_85" 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 Restrictions?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_87" 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_87" value="Other:">Other:<input class="cst_Other" name="CST_87_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_92" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_92" 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_92" value="Other:">Other:<input class="cst_Other" name="CST_92_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_93" 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_94" 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_95" 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_96" 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_97" 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 Restrictions?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" 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_103" value="Other:">Other:<input class="cst_Other" name="CST_103_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_104" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_104" 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_104" value="Other:">Other:<input class="cst_Other" name="CST_104_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_105" 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_106" 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_107" 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" style="white-space: normal; width: 50%;" draggable="false"><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 sortable-chosen" draggable="true" 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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