Online Referral
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<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">Presbyterian Hospitality House Online Referral and Application For Services </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Referral/Application for Services</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Application is for:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_267" value="Residential Services (12 years or older)">Residential Services (12 years or older)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_267" value="Therapeutic Treatment Homes">Therapeutic Treatment Homes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_267" 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" type="radio" name="CST_267" value="Behavioral Outpatient Program">Behavioral Outpatient Program</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_267" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_267_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 required">Reason for Referral (What events led up to this treatment referral?):</label><input name="CST_404" type="text" class="er_fld_required"></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>Demographic Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" 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_required er_fld_width75" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_MiddleInitial"><i class="fa fa-font"></i><label class="er_fld_label">Youth Middle Name</label><input name="CST_223" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_LastName"><i class="fa fa-font"></i><label class="er_fld_label required">Youth Last Name</label><input name="CST_226" type="text" class="er_fld_required er_fld_width100" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Nickname"> <i class="fa fa-font"></i><label class="er_fld_label">Youth Preferred Name</label><input name="CST_401" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" style="width: 20%;" 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_width75" type="text" value=""></li><li class="er_fld_type_number" style="width: 20%;" 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_radio er_fld_type_radio_col1" style="width: 20%; 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_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Preferred Pronouns</label><input name="CST_268" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><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">Religious Preference</label><select name="CST_253" class="er_fld_width100"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown">Unknown</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><option value="Other">Other</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">Ethnicity</label><select name="CST_254" class=""><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alaska Native Athabascan">Alaska Native Athabascan</option><option value="Caucasian">Caucasian</option><option value="Black/African American">Black/African American</option><option value="Bi-Racial">Bi-Racial</option><option value="Asian">Asian</option><option value="Pacific Islander">Pacific Islander</option><option value="Native Hawaiian">Native Hawaiian</option><option value="Spanish/Hispanic/Latino">Spanish/Hispanic/Latino</option><option value="Alaska Native Aleut">Alaska Native Aleut</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><option value="Native American">Native American</option><option value="Other">Other</option><option value="Unknown">Unknown</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Tribal Enrollment</label><input name="CST_288" 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 required">Current Placement (Where are they today?)</label><input name="CST_9" class="er_fld_required" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="none"> <i class="fa fa-font"></i><label class="er_fld_label required">City and State</label><input name="CST_270" type="text" class="er_fld_required er_fld_width100"></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_11" class="er_fld_width100 er_fld_required" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 20%;" draggable="false" map_to="CC_ReferringWorker_Ref"><i class="fa fa-font"></i><label class="er_fld_label required">Person Completing Application</label><input name="CST_12" class="er_fld_required er_fld_width100" type="text" value=""></li><li class="er_fld_type_number" style="width: 20%;" draggable="false" map_to="CC_ReferringPhone_Ref"><i class="fa fa-hashtag"></i><label class="er_fld_label required">Contact Phone Number</label><input name="CST_15" class="er_fld_width100 er_fld_required" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_ReferringEmail_Ref"><i class="fa fa-font"></i><label class="er_fld_label required">Contact Email</label><input name="CST_228" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Youth</label><input name="CST_281" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Intake Questionnaire</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_info">Please review the information below, then answer the following questions</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Alaskan providers are required to establish a discharge plan for every youth in care at the time they enter the program. We may not consider bringing a youth into the program without first identifying options and a plan for discharge once treatment is complete. </div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">What is the discharge plan after treatment at PHH is complete?</label><input name="CST_405" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">We require weekly family therapy sessions for youth and their families. Family members, as well as professional supports, e.g. foster parents, social workers, and probation officers, are able to play this role. If you are unable to participate, please share who would be appropriate.</div></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 required">Will you participate in weekly family therapy sessions with the youth?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_407" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_407" 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_407" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_407_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_407" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Who will participate instead?</label><input name="CST_408" type="text" class=""></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>Family Information</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 required">Mother's Name</label><input name="CST_17" class="er_fld_width100 er_fld_required" type="text" value=""></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 Contact Number</label><input name="CST_32" class="er_fld_width100" type="text" value=""></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 Address</label><input name="CST_273" type="text"></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">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><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 youth live with mom?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_271" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_271" 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_271" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_271_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 required">Is mother involved?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_276" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_276" 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_276" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_276_Other" type="text"></label> </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">Father's Name</label><input name="CST_31" class="er_fld_width100 er_fld_required" 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">Father's Contact Number</label><input name="CST_34" class="er_fld_width100" 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">Father's Address</label><input name="CST_274" type="text"></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 youth live with dad?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_272" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_272" 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_272" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_272_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 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><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">Is father involved?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_277" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_277" 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_277" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_277_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">Sibling(s) (Full name & Age of each):</label><input name="CST_275" type="text" class="er_fld_copypre"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Custody and Contact Information </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 required">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 er_fld_required" type="radio" value="Yes">Yes</label> <label class="er_option"><input name="CST_44" 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_44" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_44_Other" class="cst_Other er_fld_required" type="text"></label> </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 Social Worker?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_234" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_234" 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_234" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_234_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" style="width: 25%;" draggable="false" er_fld_condfld="CST_234" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">OCS Social Worker Name</label><input name="CST_203" type="text" value=""></li><li class="er_fld_type_number er_fld_showif" style="width: 25%;" draggable="false" er_fld_condfld="CST_234" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_47" type="text" class="er_fld_width75" value=""></li></ul><ul class="er_fld_row"><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">Does this youth have a Guardian Ad Litem (GAL)?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_282" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_282" 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_282" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_282_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_282" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Guardian Ad Litem (GAL) Name</label><input name="CST_283" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_282" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Number</label><input name="CST_284" 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_236" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_236" 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_236" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_236_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" style="width: 25%;" draggable="false" er_fld_condfld="CST_236" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Probation Worker</label><input name="CST_45" type="text"></li><li class="er_fld_type_text er_fld_showif" style="width: 25%;" draggable="false" er_fld_condfld="CST_236" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-font"></i><label class="er_fld_label">Contact Number</label><input name="CST_204" 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: 25%; 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: 25%;" 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">Tribal Worker Name</label><input name="CST_60" type="text"></li><li class="er_fld_type_number er_fld_showif" style="width: 25%;" draggable="false" er_fld_condfld="CST_59" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-hashtag"></i><label class="er_fld_label">Contact Number</label><input name="CST_61" class="er_fld_width75" type="text"></li></ul><ul class="er_fld_row"><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">Does this youth have an Attorney?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_285" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_285" 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_285" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_285_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_285" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Attorney Name</label><input name="CST_286" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_285" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Number</label><input name="CST_287" type="text"></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_bold">Contact List Please include people that the youth can be in contact with while at PHH:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name</label><input name="CST_329" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 16.6667%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Relationship</label><select name="CST_332"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Information </label><input name="CST_335" type="text"></li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Require supervision?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_342" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_342" 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_342" value="Other:">Other:<input class="cst_Other" name="CST_342_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name</label><input name="CST_330" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 16.6667%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Relationship</label><select name="CST_333"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Information</label><input name="CST_336" type="text"></li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Require supervision?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_343" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_343" 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_343" value="Other:">Other:<input class="cst_Other" name="CST_343_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Full Name</label><input name="CST_331" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 16.6667%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Relationship</label><select name="CST_334"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Information</label><input name="CST_337" type="text"></li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Require supervision?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_344" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_344" 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_344" value="Other:">Other:<input class="cst_Other" name="CST_344_Other" type="text"></label> </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_bold">Please list people that the youth may NOT have contact with or restricted contact with while at PHH:</div></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">Full Name(s) and Relationship</label><textarea name="CST_345" 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 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_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Please Enter Placement History Below </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Placement</label><input name="CST_295" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dates & Length of Stay</label><input name="CST_291" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason for Placement</label><input name="CST_296" type="text"></li><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">Completed?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_307" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_307" 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_307" value="Other:">Other:<input class="cst_Other" name="CST_307_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_298" 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"></label><input name="CST_292" 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"></label><input name="CST_299" type="text"></li><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"></label> <label class="er_option"><input class="type_radio" type="radio" name="CST_308" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_308" 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_308" value="Other:">Other:<input class="cst_Other" name="CST_308_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_293" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_301" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_302" type="text"></li><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"></label> <label class="er_option"><input class="type_radio" type="radio" name="CST_309" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_309" 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_309" value="Other:">Other:<input class="cst_Other" name="CST_309_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_294" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_304" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_305" type="text"></li><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"></label> <label class="er_option"><input class="type_radio" type="radio" name="CST_310" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_310" 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_310" value="Other:">Other:<input class="cst_Other" name="CST_310_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the youth ever been detained or incarcerated?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_290" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_290" 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_290" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_290_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_290" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please list related past, present or pending charges</label><textarea name="CST_289" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Goals for Treatment (What would you like this youth to work on at PHH?)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Goal #1</label><input name="CST_313" type="text" class="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 required">Goal #2</label><input name="CST_314" type="text" class="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 required">Goal #3</label><input name="CST_315" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Youth's Strengths</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Strength #1</label><input name="CST_316" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Strength #2</label><input name="CST_318" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Strength #3</label><input name="CST_319" type="text" class="er_fld_required"></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 check the boxes that apply to the youth's behavior</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_ReferralReason_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label required"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Anger">Anger</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Anxiety">Anxiety</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Defiant">Defiant</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Depression">Depression</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Drug Use">Drug Use</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Fighting">Fighting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Hyperactive">Hyperactive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Hopelessness/Helplessness">Hopelessness/Helplessness</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Mood Swings">Mood Swings</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Obsessive Compulsive">Obsessive Compulsive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Sleeping Problems">Sleeping Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Tantrums">Tantrums</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Property Damage">Property Damage</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Fire Setting">Fire Setting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Injury to Others">Injury to Others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Injury to Animals">Injury to Animals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Suicide Attempts">Suicide Attempts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Injury to Others">Injury to Others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_262" value="Homicidal Threats/Actions ">Homicidal Threats/Actions </label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_262" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_262_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>Trauma</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_bold">Please check the boxes that applies to trauma(s) 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" map_to="CC_RefSecReason_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label required"></label> <label class="er_option"><input name="CST_141" class="type_checkbox er_fld_required" type="checkbox" value="Chronic Neglect">Chronic Neglect</label><label class="er_option"><input name="CST_141" class="type_checkbox er_fld_required" type="checkbox" value="Domestic Violence">Domestic Violence</label><label class="er_option"><input name="CST_141" class="type_checkbox er_fld_required" type="checkbox" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input name="CST_141" class="type_checkbox er_fld_required" type="checkbox" value="Emotional Abuse">Emotional Abuse</label><label class="er_option"><input name="CST_141" class="type_checkbox er_fld_required" 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 er_fld_required" type="checkbox" value="Sexual Abuse (by non-family member)">Sexual Abuse (by non-family member)</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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>School Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected 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">Is the youth currently enrolled in school (or will be for next school year)?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_417" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_417" 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_417" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_417_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 25%;" draggable="false" map_to="CC_School_Enrolled"><i class="fa fa-circle-o"></i><label class="er_fld_label required"></label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_320" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_320" 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_320" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_320_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_320" er_fld_condvals="er_fld_showif_values=Yes" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label">Name of School</label><input name="CST_321" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_320" er_fld_condvals="er_fld_showif_values=Yes" map_to="CC_School_Grade"> <i class="fa fa-font"></i><label class="er_fld_label">Current grade level</label><input name="CST_322" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the youth been diagnosed with a learning disability?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_323" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_323" 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_323" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_323_Other" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" 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 class="type_radio" type="radio" name="CST_324" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_324" 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_324" value="Other:">Other:<input class="cst_Other" name="CST_324_Other" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false" map_to="CC_School_SpecialEd"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does the youth have an IEP?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_325" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_325" 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_325" value="Other:">Other:<input class="cst_Other" name="CST_325_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;" map_to="CC_School_Comments"> <i class="fa fa-font"></i><label class="er_fld_label">Full Scale IQ (if known):</label><input name="CST_326" type="text" class="er_fld_width50"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of IQ testing</label><input name="CST_327" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Medical</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_bold">Please attach copy of youth's immunization records along with the following inforrmation.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Known Allergies?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_351" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_351" 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_351" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_351_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_351" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">List allergies and reactions:</label><textarea name="CST_352" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of last known physical?</label><input name="CST_346" 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">Name of Clinic and Provider:</label><input name="CST_347" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date of last known dental appointment?</label><input name="CST_349" 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">Name of Clinic and Provider:</label><input name="CST_350" type="text"></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 list any medical conditions or ongoing medical or therapeutic treatment:</label><textarea name="CST_354" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does youth currently see a mental health provider?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_356" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_356" 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_356" value="Other:">Other:<input class="cst_Other" name="CST_356_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_356" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Clinic and Provider:</label><input name="CST_355" type="text"></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_bold">Current Medications</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does youth take any medication?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_410" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_410" 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_410" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_410_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_360" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage & Frequency </label><input name="CST_357" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Prescribed By?</label><input name="CST_361" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_363" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_366" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_362" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_359" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_371" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_373" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_376" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_375" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_410" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_378" type="text"></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_bold">Medical Insurance</div></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">Does Youth have Medicaid?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_398" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_398" 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_398" value="Other:">Other:<input class="cst_Other" name="CST_398_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_398" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label">Has Medicaid been applied for?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_400" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_400" 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_400" value="Other:">Other:<input class="cst_Other" name="CST_400_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_398" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Medicaid #:</label><input name="CST_399" 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: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does youth have private insurance?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_379" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_379" 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_379" value="Other:">Other:<input class="cst_Other" name="CST_379_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does youth have secondary insurance (aside from Medicaid)?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_381" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_381" 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_381" value="Other:">Other:<input class="cst_Other" name="CST_381_Other" type="text"></label> </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">Admission Screening for MRSA MRSA is a bacterium the enters the skin through open wounds to cause septicemia and is extremely resistant to most antibiotics. It has been responsible for outbreaks of untreatable infection among patients in hospitals.</div></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_bold">Step 1</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the youth have a previous history of MRSA?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_411" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_411" 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_411" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_411_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_411" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Call physician for order and obtain nasal culture and culture of previous positive site.</div></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_bold">Step 2</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_411" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does the youth have a family history of MRSA?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_415" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_415" 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_415" value="Other:">Other:<input class="cst_Other" name="CST_415_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_411" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-circle-o"></i><label class="er_fld_label">Was the youth transferred from another facility? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_416" value="Acute Care Hospital/ER or Residential Treatment Center">Acute Care Hospital/ER or Residential Treatment Center</label><label class="er_option"><input class="type_radio" type="radio" name="CST_416" value="Group Home, Foster Home or Shelter">Group Home, Foster Home or Shelter</label><label class="er_option"><input class="type_radio" type="radio" name="CST_416" value="Correctional Facility">Correctional Facility</label><label class="er_option"><input class="type_radio" type="radio" name="CST_416" value="None of the above">None of the above</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_416" value="Other:">Other:<input class="cst_Other" name="CST_416_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_416" er_fld_condvals="er_fld_showif_values=Acute+Care+Hospital%2FER+or+Residential+Treatment+Center&er_fld_showif_values=Group+Home%2C+Foster+Home+or+Shelter&er_fld_showif_values=Correctional+Facility"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Call physician for order and obtain nasal culture of previous positive site.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Primary Insurance</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Policy Holder:</label><input name="CST_382" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Youth:</label><input name="CST_383" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Employer:</label><input name="CST_384" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security #:</label><input name="CST_380" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">DOB:</label><input name="CST_388" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Policy/ID #:</label><input name="CST_385" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Group #:</label><input name="CST_387" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_379" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Insurance Co. & Mailing Address:</label><input name="CST_389" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Secondary Insurance</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Policy Holder:</label><input name="CST_390" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Youth:</label><input name="CST_391" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Employer:</label><input name="CST_392" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Social Security #</label><input name="CST_393" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">DOB:</label><input name="CST_394" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Policy ID #:</label><input name="CST_396" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Group #:</label><input name="CST_395" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_381" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Insurance C. & Mailing Address:</label><input name="CST_397" type="text"></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">I authorize the release of any medical information to process claims for the above-named youth. I request payment of government benefits be made either to Presbyterian Hospitality House, or whomever accepts assignment. I understand that I am responsible for payment of services that either my insurance or Medicaid will not cover.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_402" type="text"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 100%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_blank er_fld_width50" name="CST_403" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Additional Information</label><hr></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">Any additional information we should know about the youth</label><textarea name="CST_248" style="width:100%;" class=""></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_info">Thank you for your referral to Presbyterian Hospitality House Please Email Intake@phhalaska.org with supporting collateral for this referral. An Intake Coordinator will reach out shortly. You can also reach intake at 800-785-4756. </div></li></ul>
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