Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" style="width: 50%;" draggable="false"><i class="fa fa-header"></i><label>Admission Application</label><hr></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">Please fill out the required fields below. If it contains * that means that field is required.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Application for (check one)</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_1" value="Residential Services (12 years or older)">Residential Services (12 years or older)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_1" value="Therapeutic Treatment Homes">Therapeutic Treatment Homes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_1" value="Transition to Independent Living (18 years or older)">Transition to Independent Living (18 years or older)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_1" value="Behavioral Outpatient Program">Behavioral Outpatient Program</label><label class="er_option er_option_other er_option_other_off"><input name="CST_1" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_1_Other" class="cst_Other er_fld_required" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 25%;" draggable="false" map_to="CC_FirstName"><i class="fa fa-font"></i><label class="er_fld_label required">Youth First Name</label><input name="CST_2" class="er_fld_width100 er_fld_required" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_MiddleInitial"> <i class="fa fa-font"></i><label class="er_fld_label">Youth Middle Name</label><input name="CST_232" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Youth Last Name</label><input name="CST_233" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" style="width: 25%;" draggable="false" map_to="CC_DOB"><i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input name="CST_3" class="cst_datepicker er_fld_required er_fld_width50" type="text" value=""></li><li class="er_fld_type_number" style="width: 25%;" draggable="false" map_to="CC_SSN"><i class="fa fa-hashtag"></i><label class="er_fld_label">SSN# (Use only numbers)</label><input name="CST_4" class="er_fld_width75" type="text" value=""></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Medicaid Number</label><input name="CST_193" class="" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 25%; white-space: normal;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Sex</label> <label class="er_option"><input name="CST_6" class="type_radio er_fld_required" type="radio" value="Male">Male</label><label class="er_option"><input name="CST_6" class="type_radio er_fld_required" type="radio" value="Female">Female</label><label class="er_option er_option_other er_option_other_off"><input name="CST_6" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_6_Other" class="cst_Other er_fld_required" type="text"></label></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Religion"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Religious Preference</label><select name="CST_234" class="er_fld_required"><option value="- Not Specified - " selected="">- Not Specified - </option><option value=" Baptist"> Baptist</option><option value=" Catholic"> Catholic</option><option value=" Christian (non-denom.)"> Christian (non-denom.)</option><option value=" Jehovah Witness"> Jehovah Witness</option><option value=" Jewish"> Jewish</option><option value=" Lutheran"> Lutheran</option><option value=" Methodist"> Methodist</option><option value=" Mormon"> Mormon</option><option value=" No Preference"> No Preference</option><option value=" Pentecostal"> Pentecostal</option><option value=" Presbyterian"> Presbyterian</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Ethnicity</label><select name="CST_235" class="er_fld_required"><option value="- Not Specified - ">- Not Specified - </option><option value="Black">Black</option><option value="Asian">Asian</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Spanish/Hispanic/Latino">Spanish/Hispanic/Latino</option><option value="Native American">Native American</option><option value="Native Hawaiian">Native Hawaiian</option><option value="Pacific Islander">Pacific Islander</option><option value="Other">Other</option><option value="Alaska Native Aleut">Alaska Native Aleut</option><option value="Alaska Native Athabascan">Alaska Native Athabascan</option><option value="Alaska Native Haida">Alaska Native Haida</option><option value="Alaska Native Inupiat">Alaska Native Inupiat</option><option value="Alaska Native Tlingit">Alaska Native Tlingit</option><option value="Alaska Native Tsimshian">Alaska Native Tsimshian</option><option value="Alaska Native Yupik">Alaska Native Yupik</option><option value="Other Alaska Native">Other Alaska Native</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Yes" map_to="CC_PersonalPhone"> <i class="fa fa-font"></i><label class="er_fld_label">Youth's Phone</label><input name="CST_242" type="text" class="er_fld_width50"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_PersonalEmail"> <i class="fa fa-font"></i><label class="er_fld_label">Youth's Email Address</label><input name="CST_243" type="text" class="er_fld_width50"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Perferred Pronoun</label><input name="CST_246" type="text" class="er_fld_width50"></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_warn">Referral Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false" map_to="CC_ReferringWorker_Ref"><i class="fa fa-font"></i><label class="er_fld_label required">Name of Person Completing this Application (Referral Name)</label><input name="CST_12" class="er_fld_required er_fld_width75" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Referral Email Address</label><input name="CST_239" type="text" class="er_fld_required er_fld_width75"></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">Referral Contact Phone Number</label><input name="CST_240" type="text" class="er_fld_required er_fld_width50"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Agency Referring Youth/Source of Referral</label><select name="CST_236" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="North Star Behavioral Health">North Star Behavioral Health</option><option value="Juvenile Justice">Juvenile Justice</option><option value="Office of Children's Services">Office of Children's Services</option><option value="API">API</option><option value="Individual/Self-Referral">Individual/Self-Referral</option><option value="Other Residential/Institutional">Other Residential/Institutional</option><option value="Out of State: Psych or Res. Treatment">Out of State: Psych or Res. Treatment</option><option value="School">School</option><option value="Self Referral ">Self Referral </option><option value="Family ">Family </option><option value="Friend">Friend</option><option value="Tribal Court">Tribal Court</option><option value="Other">Other</option></select></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_warn">Parental Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Mother's Full Name</label><input name="CST_17" class="er_fld_width50" type="text"></li><li class="er_fld_type_number" style="width: 25%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Mother's Phone Number</label><input name="CST_32" class="er_fld_width50" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Mother's Email </label><input name="CST_249" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 25%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth live with mother?</label> <label class="er_option"><input name="CST_27" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_27" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_27" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_27_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 25%; white-space: normal;" draggable="false" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the mother involved?</label> <label class="er_option"><input name="CST_28" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_28" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_28" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_28_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Parental Rights Terminated?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_217" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_217" 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_217" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_217_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Full Name</label><input name="CST_31" class="er_fld_width50" type="text"></li><li class="er_fld_type_number" style="width: 33.3333%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Father's Phone Number </label><input name="CST_34" class="er_fld_width50" 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">Father's Email </label><input name="CST_250" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 25%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth live with father?</label> <label class="er_option"><input name="CST_40" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_40" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_40" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_40_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 25%; white-space: normal;" draggable="false" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the father involved?</label> <label class="er_option"><input name="CST_42" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_42" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_42" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_42_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Parental Rights Terminated?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_218" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_218" 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_218" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_218_Other" type="text"></label> </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">Siblings- Pleas list name and ages of siblings (initials of siblings may also be used for privacy)</label><input name="CST_248" type="text"></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_warn">Custody Information </div></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 custody of youth</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="State of Alaska / OCS">State of Alaska / OCS</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="DJJ (Department of Juvenile Justice)">DJJ (Department of Juvenile Justice)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="Mother">Mother</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="Father">Father</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="Joint Custody">Joint Custody</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_231" value="Tribal Custody">Tribal Custody</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_231" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_231_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please provide any current placement contact information for the youth. This can include the facility name (if applicable), current address, email address, and contact phone number.</label><textarea name="CST_238" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label required">Legal Guardian's Name(s)</label><input name="CST_48" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship to Youth</label><input name="CST_266" type="text" class="er_fld_required"></li><li class="er_fld_type_number" style="width: 25%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label required">Contact Phone Number</label><input name="CST_50" type="text" class="er_fld_width75 er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Email Address</label><input name="CST_228" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth have a Social Worker?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_237" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_237" 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_237" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_237_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" style="width: 20%;" draggable="false" er_fld_condfld="CST_237" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Name </label><input name="CST_203" type="text" class="er_fld_width100"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_237" 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_265" type="text" class="er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_237" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_268" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth have a Guardian Ad Litem (GAL)?</label> <label class="er_option"><input name="CST_53" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_53" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_53" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_53_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name </label><input name="CST_269" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_53" 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_270" type="text" class="er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" style="width: 20%;" draggable="false" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_54" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth have a Lawyer?</label> <label class="er_option"><input name="CST_56" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_56" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_56" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_56_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_56" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_271" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_56" 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_272" type="text" class="er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" style="width: 20%;" draggable="false" er_fld_condfld="CST_56" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_57" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth have a Tribal Worker?</label> <label class="er_option"><input name="CST_59" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_59" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_59" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_59_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" style="width: 20%;" draggable="false" er_fld_condfld="CST_59" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_60" type="text" class="er_fld_width100"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_59"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_273" type="text" class="er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" style="width: 20%;" draggable="false" er_fld_condfld="CST_59" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_62" class="er_fld_width75" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this youth have a Probation Officer </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_252" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_252" 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_252" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_252_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_252" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_274" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_252" 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_253" type="text" class="er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_252" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_276" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" style="width: 50%;" draggable="false"><i class="fa fa-header"></i><label></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_warn">Placement History</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the youth ever been hospitalized, placed in residential treatment, foster care home, an informal placement or placed out of state?</label> <label class="er_option"><input name="CST_65" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_65" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_65" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_65_Other" class="cst_Other er_fld_required" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small 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-paragraph"></i><label class="er_fld_label required">Please list the names of the Facilities, Dates, and Legths of stay</label><textarea name="CST_230" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is this youth currently or has this youth historically been involved with Juvenile Justice System?</label> <label class="er_option"><input name="CST_63" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_63" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_63" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_63_Other" class="cst_Other er_fld_required" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" style="width: 100%;" draggable="false" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe detentions/incarcerations, past, present and/or pending charges? </label><textarea name="CST_64" style="width: 100%;"></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_warn">Goals for Treatment</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;" map_to="CC_Goal_Ref" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please briefly list a few goals to work on in treatment- Examples may be "follow directions, make safe choices, improve family relationships, learn independent living skills..."</label><textarea name="CST_244" style="width:100%;" class="er_fld_required"></textarea></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_warn">Current Problems and Reason for Referral</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please indicate whether or not the youth displays any of the below behaviors and how long the behavior has been going on. </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Anger">Anger</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Anxiety">Anxiety</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Defiant">Defiant</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Depression">Depression</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Drug Use">Drug Use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Fighting">Fighting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Hyperactive">Hyperactive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Hopelessness/Helplessness">Hopelessness/Helplessness</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Mood Swings">Mood Swings</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Obsessive Compulsive">Obsessive Compulsive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Sleeping Problems">Sleeping Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Tantrums">Tantrums</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Property Damage">Property Damage</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Fire Setting">Fire Setting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Injury to Others">Injury to Others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Injury to Animals">Injury to Animals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Suicide Attempts">Suicide Attempts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Injury to Others">Injury to Others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="Homicidal Threats/Actions ">Homicidal Threats/Actions </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_226" value="None">None</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_226" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_226_Other" type="text"></label></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">Please breifly outline if the behaviors identified are currently present and when they first occurred </label><textarea name="CST_256" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" style="width: 50%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please check the box to indicate any trauma that the youth has experienced.</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Chronic Neglect">Chronic Neglect</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Domestic Violence ">Domestic Violence </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Emotional Abuse">Emotional Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Sexual Abuse (by family member)">Sexual Abuse (by family member)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Sexual Abuse (by non-family member)">Sexual Abuse (by non-family member)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Removal from Home Environment">Removal from Home Environment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="Socioeconomic challenges ">Socioeconomic challenges </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_141" value="None- Youth has not witnessed or experienced trauma">None- Youth has not witnessed or experienced trauma</label><label class="er_option er_option_other"><input name="CST_141" class="type_checkbox er_option_other er_fld_required" type="checkbox" value="Other:">Other:<input name="CST_141_Other" class="cst_Other er_fld_required" type="text"></label></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">Please use this box to provide clarification on trauma history including dates trauma occured and any important information about the witnessed or experienced trauma. </label><textarea name="CST_257" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" style="width: 50%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please indicate whether or not the youth displays any of the below behaviors and how long the behavior has been going on. </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="Property Damage">Property Damage</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="Injury to Animals">Injury to Animals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="Fire Setting">Fire Setting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="Injury to Others">Injury to Others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="Homicidal Threats/Acts">Homicidal Threats/Acts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_227" value="None">None</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_227" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_227_Other" type="text"></label></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">Please breifly outline if the behaviors identified are currently present and when they first occurred </label><textarea name="CST_258" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" style="width: 50%;" draggable="false"><i class="fa fa-header"></i><label></label><hr></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_warn">School Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false" map_to="CC_School_Name"><i class="fa fa-font"></i><label class="er_fld_label required">Name of School (Current or most recent)</label><input name="CST_160" class="er_fld_width100 er_fld_required" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_School_Grade"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Current Grade Level</label><select name="CST_225" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="No years of schooling">No years of schooling</option><option value="Nursery School/Pre-School (Including Head Start)">Nursery School/Pre-School (Including Head Start)</option><option value="Kindergarten">Kindergarten</option><option value="First grade">First grade</option><option value="Second grade">Second grade</option><option value="Third grade">Third grade</option><option value="Fourth grade">Fourth grade</option><option value="Fifth grade">Fifth grade</option><option value="Sixth grade">Sixth grade</option><option value="Seventh grade ">Seventh grade </option><option value="Eighth grade">Eighth grade</option><option value="Ninth grade">Ninth grade</option><option value="Tenth grade">Tenth grade</option><option value="Eleventh grade">Eleventh grade</option><option value="Twelfth grade">Twelfth grade</option><option value="GED">GED</option><option value="Certificate of Completion">Certificate of Completion</option><option value="Self-Contained Special Education Class (No equivalent grade level)">Self-Contained Special Education Class (No equivalent grade level)</option><option value="Vocational School">Vocational School</option></select></li><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Full Scale IQ (if known)</label><input name="CST_163" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the youth have a current IEP/504 Plan? </label> <label class="er_option"><input name="CST_167" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_167" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_167" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_167_Other" class="cst_Other er_fld_required" type="text"></label> </li><li class="er_fld_type_radio" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the youth need an IEP/504 ?</label> <label class="er_option"><input name="CST_168" class="type_radio er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_168" class="type_radio er_fld_required" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_168" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_168_Other" class="cst_Other er_fld_required" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" style="width: 50%;" draggable="false"><i class="fa fa-paragraph"></i><label class="er_fld_label">Does the youth have any identified struggles in school? (if applicable, please describe)</label><textarea name="CST_210" style="width: 100%;"></textarea></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_warn">Medical Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the youth currently taking any prescription or non-prescription medications?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_219" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_219" 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_219" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_219_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_219" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please list the Names of Medication and Dosage</label><textarea name="CST_229" style="width:100%;" class="er_fld_required"></textarea></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">Does this youth have any identified Allergies (including food, medication, environmental) </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_262" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_262" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_262" value="Unknown ">Unknown </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_262" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_262_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_262" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please list all known allergies for this youth </label><textarea name="CST_259" style="width:100%;"></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_warn">Additional Information </div></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">Please include any additional information as needed. </label><textarea name="CST_277" style="width:100%;"></textarea></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_warn">Signatures</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label required">Parent/Guardian Printed Name</label><input name="CST_186" class="er_fld_required er_fld_width50" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" style="width: 50%;" draggable="false"><i class="fa fa-pencil"></i><label class="er_fld_label required">Parent/Guardian Signature</label><div class="cst_signaturepad"></div><input name="CST_185" type="text" field_code="<*ES1>" class="er_fld_required"><button disabled="" class="type_button">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" style="width: 100%;" draggable="false"><i class="fa fa-calendar"></i><label class="er_fld_label required">Date</label><input name="CST_214" class="cst_datepicker er_fld_required er_fld_width25" type="text" value=""></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">Along with this application, please include any past assessments, treatment information, social history, evaluations, petitions, court documents, custody paperwork, or other documentation that will help ensure that the best possible placement can be identified for this applicant. Supporting collateral can be emailed to Intake@phhalaska.org. </div></li></ul>
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