Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content 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 Mobile/Emergency #</label><input name="CST_2" 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_3" 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_4" value="DCFS">DCFS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_4" 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_4" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_4_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_5" value="Eastern">Eastern</label><label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Northern">Northern</label><label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Salt Lake">Salt Lake</label><label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Southwest">Southwest</label><label class="er_option"><input class="type_radio" type="radio" name="CST_5" 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_5" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_5_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_6" value="DJJS Cedar City (C9Y)">DJJS Cedar City (C9Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Richfield (C5Y)">DJJS Richfield (C5Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Logan (C2Y)">DJJS Logan (C2Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Ogden (A1Y)">DJJS Ogden (A1Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Orem (A5Y)">DJJS Orem (A5Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Price (C6Y)">DJJS Price (C6Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS Salt Lake (A3Y)">DJJS Salt Lake (A3Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DJJS St. George (C7Y)">DJJS St. George (C7Y)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" 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_6" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_6_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_7" 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_8" 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_9" 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_10" 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" 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_11" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_11" 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_11" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_11_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 100%;" 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_12" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Genderqueer">Genderqueer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Gender Non-Conforming">Gender Non-Conforming</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Intergender">Intergender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Intersex">Intersex</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Nonbinary">Nonbinary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Other">Other</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Transgender">Transgender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Trans Man/Male">Trans Man/Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Trans Woman/Female">Trans Woman/Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" 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_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_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_13" 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_14" 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: 50%;" map_to="CC_Religion"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Religion</label><select name="CST_15" 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 required">Social Security #</label><input name="CST_16" type="text" class="er_fld_required"></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">DHHS Case Number</label><input name="CST_17" 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_18" 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_19" 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>Insurance Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Medicaid #</label><input name="CST_20" type="text" class="er_fld_required 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>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 Last Name</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: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent/Guardian First Name</label><input name="CST_22" type="text" class="er_fld_required 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 required">Relationship to Client</label><select name="CST_23" 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_radio" style="white-space: normal; width: 50%;" 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_24" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" 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_24" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_24_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; 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_25" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" 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_25" 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_25" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" 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_25" 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_25" 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_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address</label><input name="CST_26" 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">City</label><input name="CST_27" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">State</label><select name="CST_28" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="American Samoa">American Samoa</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District Of Columbia">District Of Columbia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Guam">Guam</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Northern Mariana Is">Northern Mariana Is</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Puerto Rico">Puerto Rico</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Virgin Islands">Virgin Islands</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option><option value=""></option></select></li><li class="er_fld_type_number" draggable="false" style="width: 50%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code</label><input name="CST_29" 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">Mobile Phone</label><input name="CST_30" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Phone</label><input name="CST_31" type="text" class="er_fld_width100"></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_32" type="text" class="er_fld_width50 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Additional 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">Parent/Guardian Last Name</label><input name="CST_33" type="text" class="er_fld_width50"></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">Parent/Guardian First Name</label><input name="CST_34" 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_35" 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_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_36" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_36" 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_36" value="Other:">Other:<input class="cst_Other" name="CST_36_Other" type="text"></label> </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_37" value="No Restrictions">No Restrictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - No Phone Calls">Restricted - No Phone Calls</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - Supervised Phone Calls Only">Restricted - Supervised Phone Calls Only</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - No Mail">Restricted - No Mail</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - No Email">Restricted - No Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - No Onsite Visits">Restricted - No Onsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" value="Restricted - No Offsite Visits">Restricted - No Offsite Visits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_37" 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_37" value="Other:">Other:<input class="cst_Other" name="CST_37_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_38" 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">City</label><input name="CST_39" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label">State</label><select name="CST_40"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="American Samoa">American Samoa</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District Of Columbia">District Of Columbia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Guam">Guam</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Northern Mariana Is">Northern Mariana Is</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Puerto Rico">Puerto Rico</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Virgin Islands">Virgin Islands</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option><option value=""></option></select></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Zip Code</label><input name="CST_41" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Mobile Phone</label><input name="CST_42" type="text" class="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">Other Phone</label><input name="CST_43" 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_44" 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>Annual Wellness Check Needs</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Medical Check in the Past 365 Days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" 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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label> </li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_45" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Medical Check</label><input class="cst_datepicker er_fld_required er_fld_blank" name="CST_46" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_45" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Action Required! Please Submit Supporting Documentation to admissions-lfl@erinbox.com</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condvals=""><i class="fa fa-circle-o"></i><label class="er_fld_label required">Vision Check in the Past 365 Days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_47" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_47" 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_47" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_47_Other" type="text"></label> </li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Vision Check</label><input class="cst_datepicker er_fld_required er_fld_blank" name="CST_48" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Action Required! Please Submit Supporting Documentation to admissions-lfl@erinbox.com</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Dental Check in the Past 365 Days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_49" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_49" 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_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label> </li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Dental Check</label><input class="cst_datepicker er_fld_required er_fld_blank" name="CST_50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Action Required! Please Submit Supporting Documentation to admissions-lfl@erinbox.com</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>Current/Ongoing Medical Needs</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=Medical+Community+Connections"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Current/Ongoing Medical Needs</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="Medical">Medical</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="Dental">Dental</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="Orthodontic">Orthodontic</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="Vision">Vision</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="Other">Other</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_51" value="None">None</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_blank er_fld_required" type="checkbox" name="CST_51" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_51_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Medical"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Medical</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Medical"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_52" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_52_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_53" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_53" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_53" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_53_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_54" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_55" type="text"></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_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_56" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_57" type="text" class="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_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_58" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_59" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_60" type="text" value="Utah" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_61" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_52" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_62" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_large" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Medical"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_63" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Dental"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Dental</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Dental"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_64" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_64" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_64" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_64_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_65" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" 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_blank" type="radio" name="CST_65" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_65_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date 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-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_66" type="text"></li><li class="er_fld_type_time 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-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_67" type="text"></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_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_68" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_69" type="text" class="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_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_70" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_71" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_72" type="text" value="Utah" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_73" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_74" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Dental"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_75" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Orthodontic"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Orthodontics</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Orthodontic"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_76" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_76" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_76" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_76_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_77" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_77" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_77" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_77_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_77" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_78" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_77" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_79" type="text"></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_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_80" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_81" type="text" class="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_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_82" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_83" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_84" type="text" class="er_fld_blank" value="Utah"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_85" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_86" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Orthodontic"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_87" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Vision"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Vision</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Vision"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_88" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_88" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_88" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_88_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_89" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" 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 er_fld_blank" type="radio" name="CST_89" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_89_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_89" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_90" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_89" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker" name="CST_91" type="text"></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_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_92" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_93" type="text" class="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_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_94" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_95" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_96" type="text" value="Utah" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_97" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_88" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_98" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Vision"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_99" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Other</div></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_51" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label">Other Current/Ongoing Medical Need Type</label><input name="CST_100" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Other"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_101" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_101" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_101" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_101_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_102" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_102" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_102" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_102_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_102" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_103" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_102" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_104" type="text"></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_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_105" type="text" class="er_fld_blank" value=""></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_106" type="text" class="er_fld_blank" value=""></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_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_107" type="text" class="er_fld_blank" value=""></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_108" type="text" class="er_fld_blank" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_109" type="text" value="Utah" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_110" type="text" class="er_fld_blank" value=""></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_101" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_111" type="text" class="er_fld_blank" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_51" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_112" 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>Current/Ongoing Medication Management - Therapy Needs</label><hr></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">Current/Ongoing Medication Management - Therapy Needs</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_113" value="Medication Management">Medication Management</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_113" value="Mental Health">Mental Health</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_113" value="Problematic Sexual Behavior (NOJOS)">Problematic Sexual Behavior (NOJOS)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_113" value="Substance Use">Substance Use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_113" value="None">None</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_113" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_113_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Medication+Management"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Medication Management</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Medication+Management"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_114" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_114" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_114" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_114_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_115" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_115" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_115" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_115_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_115" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_116" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_115" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_117" type="text"></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_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_118" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_119" type="text" value="" class="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_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_120" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_121" type="text" value="" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_122" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_123" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif er_fld_selected" draggable="false" style="width: 25%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_124" type="text" value="" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Medication+Management"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Other Comments</label><textarea name="CST_125" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Mental+Health"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Mental Health</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Mental+Health"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_126" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_126" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_126" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_126_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_127" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_127" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_127" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_127_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_127" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_128" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_127" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_129" type="text"></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_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_130" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_131" type="text" class="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_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_132" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_133" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Sate</label><input name="CST_134" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_135" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_136" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Mental+Health"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_137" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Problematic+Sexual+Behavior+(NOJOS)"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Problematic Sexual Behavior (NOJOS)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Problematic+Sexual+Behavior+(NOJOS)"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_138" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_138" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_138" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_138_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_139" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_139" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_139" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_139_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_139" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_140" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_139" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_141" type="text"></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_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_142" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_143" type="text" class="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_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_144" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_145" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_146" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_147" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_138" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_148" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Problematic+Sexual+Behavior+(NOJOS)"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_149" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Substance+Use+Disorder"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Substance Use</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif sortable-chosen" style="white-space: normal; width: 33.3333%;" draggable="true" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Substance+Use+Disorder"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Provider</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_150" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_150" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_150" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_150_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">Existing Appointment</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_151" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_151" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_151" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_151_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_151" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank" name="CST_152" type="text"></li><li class="er_fld_type_time er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_151" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker er_fld_blank" name="CST_153" type="text"></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_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Clinic Name</label><input name="CST_154" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Professional Name</label><input name="CST_155" type="text" class="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_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_156" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_157" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_158" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip Code</label><input name="CST_159" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_150" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_160" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_113" er_fld_condvals="er_fld_showif_values=Substance+Use+Disorder"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments</label><textarea name="CST_161" 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>Initial Transition Plan Building</label><hr></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">The Importance of Transition Planning at Live for Life Aspen As we support youth at Live for Life Aspen, establishing a strong foundation for their transition planning is essential. An effective initial transition plan not only sets the stage for a successful future but also empowers our young people to take ownership of their path forward. By prioritizing a clear and concise transition plan, we can better equip our youth for their next steps and foster a smoother transition into adulthood. Let’s work together to create impactful starting points that truly make a difference! </div></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>Life Skill Goals</label><hr></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">Life Skill Lessons Focusing on a manageable set of life skills is essential to support the client's transition plan, allowing youth to engage with and develop these skills fully. Life skills will be offered relative to the following goals selected. This targeted approach fosters meaningful progress and personalized support, ultimately building their confidence and promoting independence.</div></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>Life Skill Domains</label><hr></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">Please select domains from the list below that are applicable to the needs of your client.</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Court Obligations">Court Obligations</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Essential Documents">Essential Documents</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Education">Education</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Employment ">Employment </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Finance">Finance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_162" value="Housing Transition">Housing Transition</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_162" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_162_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Court+Obligations"><i class="fa fa-header"></i><label>Court Obligations Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Court+Obligations"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Court Obligations</label> <label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_163" value="Community Service Hours">Community Service Hours</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_163" value="Restitution/Fines">Restitution/Fines</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_blank" type="checkbox" name="CST_163" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_163_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_163" er_fld_condvals="er_fld_showif_values=Community+Service+Hours"> <i class="fa fa-font"></i><label class="er_fld_label required">Community Service Hours Owed</label><input name="CST_164" type="text" class="er_fld_required er_fld_blank"></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_163" er_fld_condvals="er_fld_showif_values=Restitution%2FFines"> <i class="fa fa-font"></i><label class="er_fld_label required">Restitution/Fees/Fines Amount Owed</label><input name="CST_165" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Court+Obligations"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Court Obligation Comments</label><textarea name="CST_166" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Essential+Documents"><i class="fa fa-header"></i><label>Essential Documents Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Essential+Documents"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Essential Documents Needed</label> <label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="State Issued ID">State Issued ID</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="Birth Certificate">Birth Certificate</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="Social Security Card">Social Security Card</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="Drivers License">Drivers License</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="Citizenship Documents">Citizenship Documents</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required er_fld_blank" type="checkbox" name="CST_167" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_167_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Essential+Documents"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Essential Documents Comments</label><textarea name="CST_168" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Education"><i class="fa fa-header"></i><label>Education Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Education"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Education Status</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_169" value="High School Enrollment Required">High School Enrollment Required</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_169" value="Graduated">Graduated</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_169" value="Secondary Education">Secondary Education</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_169" value="Trade School">Trade School</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_169" value="Other">Other</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_blank er_fld_required" type="checkbox" name="CST_169" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_169_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Education_B" er_fld_condfld="CST_169" er_fld_condvals="er_fld_showif_values=High+School+Enrollment+Required"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Current Grade</label><input name="CST_170" type="text" class="er_fld_width50 er_fld_blank er_fld_required"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_169" er_fld_condvals="er_fld_showif_values=High+School+Enrollment+Required"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Credits Earned</label><input name="CST_171" type="text" class="er_fld_width50 er_fld_blank er_fld_required"></li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_169" er_fld_condvals="er_fld_showif_values=High+School+Enrollment+Required"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Safe School Violations</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_172" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_172" value="No">No</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_172" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_172_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_169" er_fld_condvals="er_fld_showif_values=Other"><i class="fa fa-header"></i><label>Other Education Goal</label><hr></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_169" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Other Education Goal Type</label><input name="CST_173" type="text" class="er_fld_blank er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Education"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Education Comments</label><textarea name="CST_174" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Employment+"><i class="fa fa-header"></i><label>Employment Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Employment+"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Employment </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_175" value="Part-Time Employment">Part-Time Employment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_175" value="Full-Time Employment">Full-Time Employment</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_blank er_fld_required" type="checkbox" name="CST_175" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_175_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Employment+"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Employment Comments</label><textarea name="CST_176" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Finance"><i class="fa fa-header"></i><label>Finance Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Finance"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Finance</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_177" value="Open Bank Account">Open Bank Account</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_177" value="Saving Goal %">Saving Goal %</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_177" value="Savings Goal $">Savings Goal $</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_blank er_fld_required" type="checkbox" name="CST_177" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_177_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_177" er_fld_condvals="er_fld_showif_values=Saving+Goal+%25"> <i class="fa fa-font"></i><label class="er_fld_label required">Saving Goal %</label><input name="CST_178" type="text" class="er_fld_width25 er_fld_blank er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_177" er_fld_condvals="er_fld_showif_values=Savings+Goal+%24"> <i class="fa fa-font"></i><label class="er_fld_label required">Saving Goal $</label><input name="CST_179" type="text" class="er_fld_width25 er_fld_blank er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Finance"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Finance Comments</label><textarea name="CST_180" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Housing+Transition"><i class="fa fa-header"></i><label>Housing Transition Goal</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Housing+Transition"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Housing Transition</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="Transition to Relative">Transition to Relative</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="Transition to Lower Level of Care">Transition to Lower Level of Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="Transition to Independent Housing">Transition to Independent Housing</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_181" value="Other Transition">Other Transition</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_blank er_fld_required" type="checkbox" name="CST_181" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_181_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_181" er_fld_condvals="er_fld_showif_values=Other+Transition"><i class="fa fa-header"></i><label>Other Housing Transition </label><hr></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_181" er_fld_condvals="er_fld_showif_values=Other+Transition"> <i class="fa fa-font"></i><label class="er_fld_label required">Other Housing Transition Type</label><input name="CST_182" type="text" class="er_fld_blank er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_162" er_fld_condvals="er_fld_showif_values=Housing+Transition"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Housing Transition Comments</label><textarea name="CST_183" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">General Comments / Concerns</div></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">Please describe any comments or concerns you may have</label><textarea name="CST_184" style="width:100%;" class=""></textarea></li></ul>
Submit