Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" style="width: 100%;" draggable="false"><i class="fa fa-header"></i><label>Application</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected er_fld_type_radio_col4" style="width: 100%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Application for (check one)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_1" value="Residential Services">Residential Services</label><label class="er_option"><input class="type_radio" type="radio" name="CST_1" value="Therapeutic Foster Care">Therapeutic Foster Care</label><label class="er_option"><input class="type_radio" type="radio" name="CST_1" value="Independent Living">Independent Living</label><label class="er_option"><input class="type_radio" type="radio" name="CST_1" value="Behavioral Health Outpatient">Behavioral Health Outpatient</label><label class="er_option er_option_other er_option_other_off"><input name="CST_1" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_1_Other" class="cst_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Referred Youth</label><input name="CST_2" class="er_fld_width100" type="text" value=""></li><li class="er_fld_type_date" style="width: 33.33%;" draggable="false"><i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input name="CST_3" class="cst_datepicker er_fld_width75" type="text" value=""></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Youth ID 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: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Sex</label> <label class="er_option"><input name="CST_6" class="type_radio" type="radio" value="Male">Male</label><label class="er_option"><input name="CST_6" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_6_Other" class="cst_Other" type="text"></label></li><li class="er_fld_type_number" style="width: 50%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">SSN#</label><input name="CST_4" class="er_fld_width75" type="text" value=""></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">Religious Preference</label> <label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value="Unknown">Unknown</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Baptist"> Baptist</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Catholic"> Catholic</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Christian (non-denom.)"> Christian (non-denom.)</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Jehovah Witness"> Jehovah Witness</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Jewish"> Jewish</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Lutheran"> Lutheran</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Methodist"> Methodist</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Mormon"> Mormon</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" No Preference"> No Preference</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Pentecostal"> Pentecostal</label><label class="er_option"><input name="CST_192" class="type_checkbox" type="checkbox" value=" Presbyterian"> Presbyterian</label><label class="er_option er_option_other"><input name="CST_192" class="type_checkbox er_option_other" type="checkbox" value="Other:">Other:<input name="CST_192_Other" class="cst_Other" type="text"></label></li><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">Ethnicity</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Black/African American">Black/African American</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Asian">Asian</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Bi-Racial">Bi-Racial</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Caucasian">Caucasian</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Spanish/Hispanic/Latino">Spanish/Hispanic/Latino</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Native American">Native American</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Native Hawaiian">Native Hawaiian</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Pacific Islander">Pacific Islander</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Other">Other</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Aleut">Alaska Native Aleut</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Athabascan">Alaska Native Athabascan</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Haida">Alaska Native Haida</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Inupiat">Alaska Native Inupiat</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Tlingit">Alaska Native Tlingit</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Tsimshian">Alaska Native Tsimshian</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Alaska Native Yupik">Alaska Native Yupik</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Other Alaska Native">Other Alaska Native</label><label class="er_option er_option_other"><input name="CST_8" class="type_checkbox er_option_other" type="checkbox" value="Other:">Other:<input name="CST_8_Other" class="cst_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Current Placement</label><input name="CST_9" class="" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Phone Number</label><input name="CST_11" class="er_fld_width100" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Person Completing Application</label><input name="CST_12" class="er_fld_width50" type="text"></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">Relationship to Youth</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Mother">Mother</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Father">Father</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Step Mother">Step Mother</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Step Father">Step Father</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Adopted Mother">Adopted Mother</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Adopted Father">Adopted Father</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Other Relative">Other Relative</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_221" value="Other Non-Relative">Other Non-Relative</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_221" value="Other:">Other:<input class="cst_Other" name="CST_221_Other" type="text"></label></li><li class="er_fld_type_number" style="width: 50%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Phone Number</label><input name="CST_15" class="er_fld_width100" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="width: 100%; white-space: normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Agency Referring Youth/Source of Referral</label> <label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="North Star Behavioral Health">North Star Behavioral Health</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Juvenile Justice">Juvenile Justice</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Office of Children's Services">Office of Children's Services</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="API">API</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Individual/Self-Referral">Individual/Self-Referral</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Other Residential/Institutional">Other Residential/Institutional</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Out of State: Psych or Res. Treatment">Out of State: Psych or Res. Treatment</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="School">School</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Self, Family, Friend">Self, Family, Friend</label><label class="er_option"><input name="CST_212" class="type_checkbox" type="checkbox" value="Tribal Court">Tribal Court</label><label class="er_option er_option_other"><input name="CST_212" class="type_checkbox er_option_other" type="checkbox" value="Other:">Other:<input name="CST_212_Other" class="cst_Other" type="text"></label></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>Mother's Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Mother's Name</label><input name="CST_17" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" style="width: 50%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Mother's Phone</label><input name="CST_32" class="er_fld_width25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 100%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Mother's Email</label><input name="CST_26" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Mother's Mailing Address</label><input name="CST_21" class="er_fld_width75" type="text"></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">City</label><input name="CST_23" class="er_fld_width50" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_24" class="er_fld_width25" 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">Zip</label><input name="CST_25" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Mother's Physical Address</label><input name="CST_194" type="text"></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">City</label><input name="CST_196" class="er_fld_width50" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_195" class="er_fld_width25" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_197" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does this youth live with mother?</label> <label class="er_option"><input name="CST_27" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_27" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_27_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">If no, is mother involved?</label> <label class="er_option"><input name="CST_28" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_28" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_28_Other" class="cst_Other" type="text"></label> </li><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">Parental Rights Terminated</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_217" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" 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" type="radio" name="CST_217" value="Other:">Other:<input class="cst_Other" name="CST_217_Other" 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">Sibling(s) (Name & Age)</label><textarea name="CST_30" 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>Father's Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Name</label><input name="CST_31" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" style="width: 50%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Father's Phone</label><input name="CST_34" class="er_fld_width25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Email</label><input name="CST_198" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Mailing Address</label><input name="CST_35" class="er_fld_width75" type="text"></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">City</label><input name="CST_36" class="er_fld_width50" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_37" class="er_fld_width25" 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">Zip</label><input name="CST_39" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Physical Address</label><input name="CST_199" type="text"></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">City</label><input name="CST_201" class="er_fld_width50" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_200" class="er_fld_width25" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_202" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does this youth live with father?</label> <label class="er_option"><input name="CST_40" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_40" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_40_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 33.3333%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">If no, is father involved?</label> <label class="er_option"><input name="CST_42" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_42" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_42_Other" class="cst_Other" type="text"></label> </li><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">Parental Rights Terminated</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_218" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" 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" type="radio" name="CST_218" value="Other:">Other:<input class="cst_Other" name="CST_218_Other" 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">Sibling(s) (Name & Age)</label><textarea name="CST_43" style="width: 100%;"></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">Is youth in the custody of the state of the State of Alaska?</label> <label class="er_option"><input name="CST_44" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_44" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_44" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_44_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Probation</label><input name="CST_45" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_47" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">OCS- Social Worker</label><input name="CST_203" type="text"></li><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Contact Number</label><input name="CST_204" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">If no: Legal Guardian's Name</label><input name="CST_48" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_50" type="text"></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_info">If parent is not involved please attach copy of custody paperwork.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Was youth adopted?</label> <label class="er_option"><input name="CST_51" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_51" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_51" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_51_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of Adoption</label><input name="CST_224" type="text" class="er_fld_width50"></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">Does this youth have a Guardian Ad Litem (GAL)?</label> <label class="er_option"><input name="CST_53" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_53" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_53_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_54" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_55" class="er_fld_width50" type="text"></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">Does this youth have a Lawyer?</label> <label class="er_option"><input name="CST_56" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_56" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_56_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_57" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_58" class="er_fld_width50" type="text"></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">Does this youth have a Tribal Worker?</label> <label class="er_option"><input name="CST_59" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_59" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_59_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_60" type="text"></li><li class="er_fld_type_number" style="width: 33.33%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_61" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Tribal Enrollment</label><input name="CST_62" class="er_fld_width50" type="text"></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">Is youth involved with Juvenile Justice System?</label> <label class="er_option"><input name="CST_63" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_63" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_63_Other" class="cst_Other" 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">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_section" style="width: 50%;" draggable="false"><i class="fa fa-header"></i><label>Placement History</label><hr></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">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" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_65" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_65_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Name of Facility</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Dates & Length of Stay</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Reason for Placement</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Completed Yes/No</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_68" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_67" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_69" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label"></label> <label class="er_option"><input name="CST_87" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_87" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_87" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_87_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_72" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_71" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_73" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label"></label> <label class="er_option"><input name="CST_88" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_88" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_88" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_88_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_76" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_75" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_77" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label"></label> <label class="er_option"><input name="CST_89" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_89" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_89" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_89_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_80" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_79" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_81" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label"></label> <label class="er_option"><input name="CST_90" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_90" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_90" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_90_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_83" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_84" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_85" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label"></label> <label class="er_option"><input name="CST_91" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_91" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_91" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_91_Other" class="cst_Other" type="text"></label> </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>Goals for Treatment</label><hr></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">1.</label><input name="CST_93" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">2.</label><input name="CST_94" type="text"></li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">3.</label><input name="CST_95" type="text"></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>Current Problems and Reason for Referral</label><hr></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">Please indicate whether or not the youth displays any of the below behaviors and how long the behavior has been going on. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Anger</label> <label class="er_option"><input name="CST_97" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_97" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_97" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_97_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_123" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Anxiety</label> <label class="er_option"><input name="CST_99" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_99" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_99" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_99_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_124" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Defiant</label> <label class="er_option"><input name="CST_101" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_101" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_101" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_101_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_125" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Depression</label> <label class="er_option"><input name="CST_103" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_103" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_103" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_103_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_129" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Drug Use</label> <label class="er_option"><input name="CST_105" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_105" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_105" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_105_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_130" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Fighting</label> <label class="er_option"><input name="CST_107" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_107" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_107" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_107_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_131" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 25%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Hyperactive</label> <label class="er_option"><input name="CST_111" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_111" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_111" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_111_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_132" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 25%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Hopelessness/Helplessness</label> <label class="er_option"><input name="CST_109" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_109" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_109" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_109_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 25%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_134" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Mood Swings</label> <label class="er_option"><input name="CST_113" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_113" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_113" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_113_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_135" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Obsessive/Compulsive</label> <label class="er_option"><input name="CST_115" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_115" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_115" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_115_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_136" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Sleeping Problems</label> <label class="er_option"><input name="CST_117" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_117" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_117" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_117_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_137" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Tantrums</label> <label class="er_option"><input name="CST_119" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_119" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_119" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_119_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_138" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Other (describe below)</label><input name="CST_121" type="text"></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_139" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Other (describe below)</label><input name="CST_128" type="text"></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_140" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" style="width: 100%;" draggable="false"><i class="fa fa-header"></i><label>Trauma</label><hr></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">Please check the box to indicate any trauma that the youth has experienced.</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">Trauma Experience</label> <label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Chronic Neglect">Chronic Neglect</label><label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Domestic Violence">Domestic Violence</label><label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Emotional Abuse">Emotional Abuse</label><label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Sexual Abuse (by family member)">Sexual Abuse (by family member)</label><label class="er_option"><input name="CST_141" class="type_checkbox" type="checkbox" value="Sexual Abuse (by non-family member)">Sexual Abuse (by non-family member)</label><label class="er_option er_option_other er_option_other_off"><input name="CST_141" class="type_checkbox er_option_other" type="checkbox" value="Other:">Other:<input name="CST_141_Other" class="cst_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Other (describe below)</label><input name="CST_142" type="text"></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Other (describe below)</label><input name="CST_143" type="text"></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>Other Behaviors</label><hr></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">Please indicate whether or not the youth displays any of the below behaviors and how long the behavior has been going on. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Property Damage</label> <label class="er_option"><input name="CST_145" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_145" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_145" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_145_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_146" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Injury to Animals</label> <label class="er_option"><input name="CST_147" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_147" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_147" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_147_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_148" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Fire Setting</label> <label class="er_option"><input name="CST_149" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_149" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_149" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_149_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_150" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Suicide Attempts</label> <label class="er_option"><input name="CST_151" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_151" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_151" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_151_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_153" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Injury to Others</label> <label class="er_option"><input name="CST_154" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_154" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_154" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_154_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_155" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="width: 20%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Homicidal Threats/Acts</label> <label class="er_option"><input name="CST_156" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_156" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_156" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_156_Other" class="cst_Other" type="text"></label> </li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Dates</label><input name="CST_157" type="text"></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>Strengths</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">1.</label><input name="CST_206" type="text"></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">2.</label><input name="CST_205" type="text"></li><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">3.</label><input name="CST_207" type="text"></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>School Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Is the youth currently enrolled in school (or will be for next school year)? </label> <label class="er_option"><input name="CST_159" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_159" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_159" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_159_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 50%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Name of School</label><input name="CST_160" class="er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Current Grade Level</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="No years of schooling">No years of schooling</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Nursery School/Pre-School (Including Head Start)">Nursery School/Pre-School (Including Head Start)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Kindergarten">Kindergarten</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="First grade">First grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Second grade">Second grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Third grade">Third grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Fourth grade">Fourth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Fifth grade">Fifth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Sixth grade">Sixth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Seventh grade ">Seventh grade </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Eighth grade">Eighth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Ninth grade">Ninth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Tenth grade">Tenth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Eleventh grade">Eleventh grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Twelfth grade">Twelfth grade</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="GED">GED</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Certificate of Completion">Certificate of Completion</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Self-Contained Special Education Class (No equivalent grade level)">Self-Contained Special Education Class (No equivalent grade level)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Vocational School">Vocational School</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_222" value="Other:">Other:<input class="cst_Other" name="CST_222_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" style="width: 50%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Current Grade Level</label><input name="CST_162" class="er_fld_width25" type="text"></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">Full Scale IQ (if known)</label><input name="CST_163" type="text"></li><li class="er_fld_type_date" style="width: 33.3333%;" draggable="false"><i class="fa fa-calendar"></i><label class="er_fld_label">Dates testing was completed (approximate)</label><input name="CST_165" class="cst_datepicker er_fld_width50" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Has the youth been diagnosed with a learning disability? </label> <label class="er_option"><input name="CST_166" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_166" class="type_radio" type="radio" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input name="CST_166" class="type_radio er_option_other" type="radio" value="Other:">Other:<input name="CST_166_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Is there a 504 Plan? </label> <label class="er_option"><input name="CST_167" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_167" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_167_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="width: 50%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does the youth have an IEP ?</label> <label class="er_option"><input name="CST_168" class="type_radio" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_168" class="type_radio" 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" type="radio" value="Other:">Other:<input name="CST_168_Other" class="cst_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" style="width: 100%;" draggable="false"><i class="fa fa-paragraph"></i><label class="er_fld_label">Other School Problems (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_section" style="width: 50%;" draggable="false"><i class="fa fa-header"></i><label>Current Medications</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Currently Taking Medications?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_219" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" 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" type="radio" name="CST_219" value="Other:">Other:<input class="cst_Other" name="CST_219_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Name of Medication</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Dosage</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Time</div></li><li class="er_fld_type_content" style="width: 20%;" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Prescribed By?</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_170" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_171" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_172" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_169" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_174" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_176" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_175" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_173" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_179" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_180" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_178" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_177" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_183" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_184" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_182" type="text"></li><li class="er_fld_type_text" style="width: 20%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_181" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" style="width: 100%;" draggable="false"><i class="fa fa-header"></i><label>Signatures</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.33%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Parent/Guardian Printed Name</label><input name="CST_186" class="er_fld_width75" type="text" value="<*EN1>"></li><li class="er_fld_type_date" style="width: 33.33%;" draggable="false"><i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input name="CST_214" class="cst_datepicker" type="text" value="<*ED1>"></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">Parent/Guardian Signature</label><div class="cst_signaturepad"></div><input name="CST_185" type="text" field_code="<*ES1>"><button disabled="" class="type_button">Clear Signature</button></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">Placing Agency Rep. Printed Name</label><input name="CST_187" class="er_fld_width75" type="text" value="<*EN2>"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Title</label><input name="CST_220" type="text"></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">Placing Agency Rep. Signature</label><div class="cst_signaturepad"></div><input name="CST_188" type="text" field_code="<*ES2>"><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">Date</label><input name="CST_215" class="cst_datepicker er_fld_width50" type="text" value="<*ED2>"></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 also include any past assessments, treatment information, social history, evaluations, petitions, court documents etc.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label">Single Line Text</label><input name="CST_223" type="text"></li></ul>
Submit