Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Referral Application</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col2" style="width: 100%; white-space: normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Application for (check one)</label> <label class="er_option"><input class="type_radio" 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 Outpatient Program">Behavioral Outpatient Program</label><label class="er_option er_option_other er_option_other_off"><input name="CST_1" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_1_Other" class="cst_Other er_fld_required" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" style="width: 100%;" 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></ul><ul class="er_fld_row"><li class="er_fld_type_date" style="width: 33.3333%;" 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="<DOB>"></li><li class="er_fld_type_number" style="width: 33.3333%;" draggable="false" map_to="CC_SSN"><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><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false" map_to="none"><i class="fa fa-font"></i><label class="er_fld_label">Medicaid Number</label><input name="CST_193" class="" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="width: 33.3333%; white-space: normal;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Sex</label> <label class="er_option"><input name="CST_6" class="type_radio er_fld_required" type="radio" value="Male">Male</label><label class="er_option"><input name="CST_6" class="type_radio er_fld_required" type="radio" value="Female">Female</label><label class="er_option er_option_other er_option_other_off"><input name="CST_6" class="type_radio er_option_other er_fld_required" type="radio" value="Other:">Other:<input name="CST_6_Other" class="cst_Other er_fld_required" type="text"></label></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" 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: 33.3333%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label">Ethnicity</label><select name="CST_254"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown">Unknown</option><option value="Black/African American">Black/African American</option><option value="Asian">Asian</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Spanish/Hispanic/Latino">Spanish/Hispanic/Latino</option><option value="Native American">Native American</option><option value="Native Hawaiian">Native Hawaiian</option><option value="Native Alaskan">Native Alaskan</option><option value="Pacific Islander">Pacific Islander</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label required">Current Placement</label><input name="CST_9" class="er_fld_required" type="text"></li><li class="er_fld_type_number" style="width: 33.3333%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label 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: 25%;" 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"></li><li class="er_fld_type_number" style="width: 25%;" 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"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" 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"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Relationship to Youth</label><select name="CST_255" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Mother">Mother</option><option value="Father">Father</option><option value="Step Mother">Step Mother</option><option value="Step Father">Step Father</option><option value="Adopted Mother">Adopted Mother</option><option value="Adopted Father">Adopted Father</option><option value="Other Relative">Other Relative</option><option value="Other Non-Relative">Other Non-Relative</option><option value="Other">Other</option></select></li><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 er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_258" value="Other:">Other:<input class="cst_Other" name="CST_258_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>Parent Information</label><hr></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">Mother's Name</label><input name="CST_17" class="er_fld_width100" type="text" value=""></li><li class="er_fld_type_number" style="width: 33.3333%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Mother's Phone Number</label><input name="CST_32" class="er_fld_width100" type="text" value=""></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_217" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_217" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_217" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_217_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" style="width: 33.3333%;" draggable="false"><i class="fa fa-font"></i><label class="er_fld_label">Father's Name</label><input name="CST_31" class="er_fld_width100" type="text"></li><li class="er_fld_type_number" style="width: 33.3333%;" draggable="false"><i class="fa fa-hashtag"></i><label class="er_fld_label">Father's Phone</label><input name="CST_34" class="er_fld_width100" type="text"></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></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Custody 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" style="width: 25%;" draggable="false"><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_selected" style="width: 25%;" draggable="false"><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 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" style="width: 25%;" draggable="false"><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" style="width: 25%;" draggable="false"><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" style="width: 25%;" 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: 25%;" draggable="false"><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_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_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label">Name and Location of Prior Placements</label><textarea name="CST_266" 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 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.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_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: 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" map_to="CC_RefSecReason_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></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"><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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Additional Information</label><hr></li></ul><ul class="er_fld_row" id="er_row_last"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"><i class="fa fa-paragraph"></i><label class="er_fld_label">Any additional information we should know about the youth</label><textarea name="CST_248" style="width:100%;"></textarea></li></ul>
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