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 Secure Care Services Transition coaches provide individual and group psychosocial rehabilitative services (PRS) to youth in secure care to help them prepare to transition out of secure care into the community successfully.</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" draggable="false" style="width: 33.3333%;" map_to="CC_Language"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Language</label><select name="CST_68" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Arabic">Arabic</option><option value="Bengali">Bengali</option><option value="Chinese">Chinese</option><option value="English">English</option><option value="French">French</option><option value="German">German</option><option value="Hindi">Hindi</option><option value="Japanese">Japanese</option><option value="Lahnda">Lahnda</option><option value="Marathi">Marathi</option><option value="Portuguese">Portuguese</option><option value="Russian">Russian</option><option value="Spanish">Spanish</option><option value="Tagalog">Tagalog</option><option value="Tamil">Tamil</option><option value="Turkish">Turkish</option><option value="Urdu">Urdu</option><option value="Vietnamese">Vietnamese</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" 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_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 er_fld_selected" draggable="false" style="width: 100%;" 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%;"><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">Parent/Guardian</label><input name="CST_18" 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 -" 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_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_19" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_20" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_21" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Parent/Guardian</label><input name="CST_22" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_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_70"><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_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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