Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Live for Life Aftercare Services (FFPSA) Transition coaches provide support to youth when they are discharged from a qualified residential treatment program and transition to a biological family home, foster home, or independent living environment. These services are provided for six months and are designed to maximize a successful transition and prevent a return to a residential placement or re-entry into the care of the Department of Health and Human Services. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Case Management Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Case Manager Name</label><input name="CST_1" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Case Manager Cell/Emergency #</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Case Manager Email</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DHHS Agency</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="DCFS">DCFS</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="DJJYS">DJJYS</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_64" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_64_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" map_to="CC_ReferralSource_Ref" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=DCFS"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DCFS Region</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Eastern">Eastern</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Northern">Northern</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Salt Lake">Salt Lake</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Southwest">Southwest</label><label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_65" value="Western">Western</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank er_fld_required" type="radio" name="CST_65" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_65_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_ReferralSource_Ref" er_fld_condfld="CST_64" er_fld_condvals="er_fld_showif_values=DJJYS"><i class="fa fa-circle-o"></i><label class="er_fld_label required">DJJYS Office</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Cedar City (C9Y)">DJJS Cedar City (C9Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Richfield (C5Y)">DJJS Richfield (C5Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Logan (C2Y)">DJJS Logan (C2Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Ogden (A1Y)">DJJS Ogden (A1Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Orem (A5Y)">DJJS Orem (A5Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Price (C6Y)">DJJS Price (C6Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Salt Lake (A3Y)">DJJS Salt Lake (A3Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS St. George (C7Y)">DJJS St. George (C7Y)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_9" value="DJJS Vernal (C4Y)">DJJS Vernal (C4Y)</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_9" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_9_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Client First Name</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">DOB</label><input class="cst_datepicker er_fld_required" name="CST_12" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Age</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_62" value="Female">Female</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_62" value="Male">Male</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_62" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_62_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CustomField_Value_8"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender Identity</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Genderqueer">Genderqueer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Gender Non-Conforming">Gender Non-Conforming</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Intergender">Intergender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Intersex">Intersex</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Nonbinary">Nonbinary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Other">Other</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Transgender">Transgender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Trans Man/Male">Trans Man/Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="Trans Woman/Female">Trans Woman/Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_63" value="I do not wish to provide this information">I do not wish to provide this information</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Race"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_67" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown">Unknown</option><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 33.3333%;" map_to="CC_Language"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Language</label><select name="CST_68" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Arabic">Arabic</option><option value="Bengali">Bengali</option><option value="Chinese">Chinese</option><option value="English">English</option><option value="French">French</option><option value="German">German</option><option value="Hindi">Hindi</option><option value="Japanese">Japanese</option><option value="Karen">Karen</option><option value="Lahnda">Lahnda</option><option value="Marathi">Marathi</option><option value="Portuguese">Portuguese</option><option value="Russian">Russian</option><option value="Spanish">Spanish</option><option value="Swahili">Swahili</option><option value="Tagalog">Tagalog</option><option value="Tamil">Tamil</option><option value="Turkish">Turkish</option><option value="Urdu">Urdu</option><option value="Vietnamese">Vietnamese</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;" map_to="CC_Religion"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Religion</label><select name="CST_69" class="er_fld_width50"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Buddhist">Buddhist</option><option value="Catholic">Catholic</option><option value="Christian">Christian</option><option value="Evangelical">Evangelical</option><option value="Hindu">Hindu</option><option value="Islam">Islam</option><option value="Jehovah Witness">Jehovah Witness</option><option value="Jewish">Jewish</option><option value="LDS">LDS</option><option value="Protestant">Protestant</option><option value="Declined">Declined</option><option value="None">None</option><option value="Other">Other</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security #</label><input name="CST_14" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_6"> <i class="fa fa-font"></i><label class="er_fld_label required">Case Number</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Referral Date</label><input class="cst_datepicker er_fld_required" name="CST_16" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_7"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Service Start Date</label><input class="cst_datepicker er_fld_required" name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Prior Placement</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_75" value="Live for Life Cypress">Live for Life Cypress</label><label class="er_option"><input class="type_radio" type="radio" name="CST_75" value="Live for Life Sequoia">Live for Life Sequoia</label><label class="er_option"><input class="type_radio" type="radio" name="CST_75" value="Other Qualified Residential Treatment Program">Other Qualified Residential Treatment Program</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_75" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_75_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>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">Medicaid #</label><input name="CST_26" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Mentoring+Services+(MT1)&er_fld_showif_values=After+Care+Services+(NNC)"><i class="fa fa-header"></i><label>History of Concerns</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" er_fld_condvals="er_fld_showif_values=Mentoring+Services+(MT1)"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please Select All That Apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Family Gang Involvement ">Family Gang Involvement </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Individual Gang Involvement ">Individual Gang Involvement </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Family Issues">Family Issues</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Assaultive">Assaultive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="AWOL">AWOL</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Psychiatric">Psychiatric</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Substance Use">Substance Use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Sexual Abuse">Sexual Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_56" value="Suicidal Ideation">Suicidal Ideation</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_56" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_56_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Education</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Education"> <i class="fa fa-font"></i><label class="er_fld_label">Current Grade</label><input name="CST_52" type="text" class=""></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Credits</label><input name="CST_53" 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">Safe School Violations</label><input name="CST_54" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">School Comments</label><textarea name="CST_74" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Parent/Guardian Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Parent/Guardian Name</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Relationship to Client</label><select name="CST_70" class="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></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_72" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_72" 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_72" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_72_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone</label><input name="CST_19" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address</label><input name="CST_20" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_21" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Parent/Guardian Name</label><input name="CST_22" type="text"></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_71"><option value="- Not Specified -">- Not Specified -</option><option value="Guardian - Aunt">Guardian - Aunt</option><option value="Guardian - Father">Guardian - Father</option><option value="Guardian - Grandfather">Guardian - Grandfather</option><option value="Guardian - Grandmother">Guardian - Grandmother</option><option value="Guardian - Mother">Guardian - Mother</option><option value="Guardian - Other">Guardian - Other</option><option value="Guardian - Step-Father">Guardian - Step-Father</option><option value="Guardian - Step-Mother">Guardian - Step-Mother</option><option value="Guardian - Uncle">Guardian - Uncle</option><option value="Guardian Ad-Litem">Guardian Ad-Litem</option><option value="Non-Guardian - Aunt">Non-Guardian - Aunt</option><option value="Non-Guardian - Father">Non-Guardian - Father</option><option value="Non-Guardian - Grandfather">Non-Guardian - Grandfather</option><option value="Non-Guardian - Grandmother">Non-Guardian - Grandmother</option><option value="Non-Guardian - Mother">Non-Guardian - Mother</option><option value="Non-Guardian - Other">Non-Guardian - Other</option><option value="Non-Guardian - Step-Father">Non-Guardian - Step-Father</option><option value="Non-Guardian - Step-Mother">Non-Guardian - Step-Mother</option><option value="Non-Guardian - Uncle">Non-Guardian - Uncle</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other Relative">Other Relative</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_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_73" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_73" 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_73" value="Other:">Other:<input class="cst_Other" name="CST_73_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_23" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_24" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_25" type="text"></li></ul>
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