Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 25%;"><i class="fa fa-header"></i><label>Potential Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Name_First" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Client First Name </label><input name="CST_1" type="text" class="er_fld_required"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></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_24" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="Nothing"> <i class="fa fa-font"></i><label class="er_fld_label">-OR- Initials</label><input name="CST_2" type="text" value="" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Phone Number</label><input name="CST_26" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Email Address</label><input name="CST_27" type="text" class="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>Referring Agency/Worker 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_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referring Agency/County/School/Individual</label><input name="CST_8" 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">Your Name</label><input name="CST_9" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone</label><input name="CST_10" type="text" class="er_fld_required"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="Nothing"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3 er_fld_selected" style="white-space:normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Service Requested </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="CBS">CBS</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Education">Education</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Family Engagement">Family Engagement</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_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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Personal and Family</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Gender"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Male">Male</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Transgender">Transgender</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Female">Female</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_15" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_15_Other" type="text"></label></li><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">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_25" 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>Education</label><hr></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">School Name</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_1"> <i class="fa fa-font"></i><label class="er_fld_label required">School District </label><input name="CST_17" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2 sortable-chosen" style="white-space: normal; width: 33.3333%;" draggable="true"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">IEP</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_19" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_19" value="No">No</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_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li><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 required">Grade </label><input name="CST_18" type="text" class="er_fld_required er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reason for Referral</label><textarea name="CST_20" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How did you hear about Advocates for Healthy Transitional Living?</label><textarea name="CST_23" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Any other helpful information </label><textarea name="CST_22" style="width:100%;"></textarea></li></ul>
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