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"><img src="data:image/png;base64,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"></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>CLIENT IDENTIFYING DATA</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Client First Name</label><input name="CST_3" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name</label><input name="CST_178" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="CC_DOB"> <i class="fa fa-font"></i><label class="er_fld_label required">Date of Birth</label><input name="CST_5" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Age</label><input name="CST_4" type="text" value="" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.333333333333336%;" map_to="CC_Gender"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_6" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Female">Female</option><option value="Male">Male</option><option value="Trans-MTF">Trans-MTF</option><option value="Trans-FTM">Trans-FTM</option><option value="Genderqueer-Trans">Genderqueer-Trans</option><option value="Decline to Answer">Decline to Answer</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Sexual Orientation</label><select name="CST_7" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Heterosexual">Heterosexual</option><option value="Bisexual">Bisexual</option><option value="Asexual">Asexual</option><option value="Gay">Gay</option><option value="Lesbian">Lesbian</option><option value="Pansexual">Pansexual</option><option value="Queer">Queer</option><option value="Other">Other</option><option value="Decline to Answer">Decline to Answer</option></select></li><li class="er_fld_type_checkbox er_fld_selected" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Pronoun</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_237" value="She/Her">She/Her</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_237" value="He/Him">He/Him</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_237" value="They/Them">They/Them</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_237" value="Prefer not to use pronouns">Prefer not to use pronouns</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_237" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_237_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Physical Address</label><input name="CST_8" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_179" type="text" class="er_fld_required" value="NM"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip</label><input name="CST_180" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Mailing Address (if different from above)</label><input name="CST_10" type="text" class=""></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">City</label><input name="CST_11" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_181" 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">Zip</label><input name="CST_182" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Home Phone</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Cell Phone</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Work"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone</label><input name="CST_14" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_126" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does the client have children?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" 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_15" value="Other:">Other:<input class="cst_Other" name="CST_15_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.333333333333336%;" map_to="CC_Race"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_16" class="er_fld_required"><option value="-Not specified-" selected="">-Not specified-</option><option value="Asian">Asian</option><option value="African American">African American</option><option value="Anglo">Anglo</option><option value="American Indian">American Indian</option><option value="Multi-Racial">Multi-Racial</option></select></li><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Ethnicity</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" value="Hispanic">Hispanic</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" value="Non-Hispanic">Non-Hispanic</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_17" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_17_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Tribal Affiliation</label><input name="CST_18" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Census #</label><input name="CST_19" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;" map_to="CC_Language"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Language</label><input name="CST_20" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Language</label><input name="CST_21" type="text"></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>Mental Health Questionnaire Instructions</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">1. Check the applicable box for each question below. 2. If “YES” is checked, circle all behaviors that apply. Failure to circle the appropriate behaviors will result in your services inquiry being marked “INCOMPLETE”. 3. This list is not exhaustive. If you have a question about whether or not to check “YES,” please indicate the issues under the COMMENTS section or you can call us at 505-325-5358 ext 130. 4. You can return this form to 406 Airport Rd. Farmington NM 87401 or fax to 505-564-8368.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments and/or Additional Information</label><textarea name="CST_187" style="width:100%;"></textarea></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">1. Has this child been a danger to themself or to others in the last 90 days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_188" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_188" 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_188" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_188_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Attempted suicide">Attempted suicide</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Made suicidal gestures">Made suicidal gestures</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Expressed suicidal ideation">Expressed suicidal ideation</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Assaultive to other children or adults">Assaultive to other children or adults</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Reckless and/or puts self in dangerous situations">Reckless and/or puts self in dangerous situations</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_189" value="Attempts to or has sexually assaulted or molested other children">Attempts to or has sexually assaulted or molested other children</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_189" value="Other:">Other:<input class="cst_Other" name="CST_189_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_190" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_190" 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_190" value="Other:">Other:<input class="cst_Other" name="CST_190_Other" type="text"></label> </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">2. Has this child experienced physical or sexual abuse or have they been exposed to violent behavior in the last 90 days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_191" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_191" 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_191" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_191_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Subjected to or witnessed physical abuse">Subjected to or witnessed physical abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Subjected to or witnessed domestic violence ">Subjected to or witnessed domestic violence </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Subjected to or witnessed sexual abuse">Subjected to or witnessed sexual abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Severe bruising in unusual areas">Severe bruising in unusual areas</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Forced to watch torture or sexual assault">Forced to watch torture or sexual assault</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_192" value="Witness to murder">Witness to murder</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_192" value="Other:">Other:<input class="cst_Other" name="CST_192_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_193" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_193" 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_193" value="Other:">Other:<input class="cst_Other" name="CST_193_Other" type="text"></label> </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">3a. Does this child have behaviors that are so difficult that maintaining them in their current living or educational situation is in jeopardy?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_194" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_194" 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_194" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_194_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all behaviors that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Persistent chaotic, impulsive or disruptive behaviors">Persistent chaotic, impulsive or disruptive behaviors</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Daily verbal outbursts">Daily verbal outbursts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Excessive noncompliance">Excessive noncompliance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Constantly challenges the authority of caregiver">Constantly challenges the authority of caregiver</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Requires constant direction and supervision in all activities">Requires constant direction and supervision in all activities</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Requires total attention of caregiver">Requires total attention of caregiver</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Overly jealous of caregiver’s other relationships">Overly jealous of caregiver’s other relationships</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Disruptive levels of activity">Disruptive levels of activity</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Wanders the house at night">Wanders the house at night</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Excessive truancy">Excessive truancy</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_195" value="Fails to respond to limit setting or other discipline">Fails to respond to limit setting or other discipline</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_195" value="Other:">Other:<input class="cst_Other" name="CST_195_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_196" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_196" 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_196" value="Other:">Other:<input class="cst_Other" name="CST_196_Other" type="text"></label> </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">4a. Has the child exhibited bizarre or unusual behaviors in the last 90 days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_197" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_197" 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_197" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_197_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all behaviors that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="History or pattern of fire-setting">History or pattern of fire-setting</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Cruelty to animals">Cruelty to animals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Excessive, compulsive or public masturbation">Excessive, compulsive or public masturbation</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Appears to hear voices or respond to other internal stimuli (including alcohol or drug induced)">Appears to hear voices or respond to other internal stimuli (including alcohol or drug induced)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Repetitive body motions (e.g., head banging) or vocalizations (e.g., echolalia)">Repetitive body motions (e.g., head banging) or vocalizations (e.g., echolalia)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_198" value="Smears feces">Smears feces</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_198" value="Other:">Other:<input class="cst_Other" name="CST_198_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_199" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_199" 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_199" value="Other:">Other:<input class="cst_Other" name="CST_199_Other" type="text"></label> </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">5. Does the child have problems with social adjustment?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_200" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_200" 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_200" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_200_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all behaviors that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Regularly involved in physical fights with other children or adults">Regularly involved in physical fights with other children or adults</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Verbally threatens people">Verbally threatens people</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Damages possessions of self or others">Damages possessions of self or others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Runs away">Runs away</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Truant; steals">Truant; steals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Regularly lies">Regularly lies</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Mute">Mute</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Confined due to serious law violations">Confined due to serious law violations</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_201" value="Does not seem to feel guilt after misbehavior">Does not seem to feel guilt after misbehavior</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_201" value="Other:">Other:<input class="cst_Other" name="CST_201_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_202" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_202" 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_202" value="Other:">Other:<input class="cst_Other" name="CST_202_Other" type="text"></label> </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">6. Does this child have problems making and maintaining healthy relationships?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_203" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_203" 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_203" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_203_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_204" value="Unable to form positive relationships with peers">Unable to form positive relationships with peers</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_204" value="Provokes and victimizes other children">Provokes and victimizes other children</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_204" value="Gang involvement">Gang involvement</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_204" value="Does not form bond with caregiver, etc.">Does not form bond with caregiver, etc.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_204" value="Other:">Other:<input class="cst_Other" name="CST_204_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_205" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_205" 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_205" value="Other:">Other:<input class="cst_Other" name="CST_205_Other" type="text"></label> </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">7. Does this child have problems with personal care?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_206" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_206" 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_206" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_206_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_207" value="Eats or drinks substances that are not food">Eats or drinks substances that are not food</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_207" value="Regularly enuretic (wets pants) during waking hours (subject to age of child)">Regularly enuretic (wets pants) during waking hours (subject to age of child)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_207" value="Extremely poor personal hygiene">Extremely poor personal hygiene</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_207" value="Other:">Other:<input class="cst_Other" name="CST_207_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_208" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_208" 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_208" value="Other:">Other:<input class="cst_Other" name="CST_208_Other" type="text"></label> </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">8. Does this child have significant functional impairment?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_209" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_209" 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_209" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_209_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_210" value="No known history of developmental disorder and behavior interferes with ability to learn at school">No known history of developmental disorder and behavior interferes with ability to learn at school</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_210" value="Significantly delayed in language">Significantly delayed in language</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_210" value=""Not socialized” and incapable of managing basic age appropriate skills">"Not socialized” and incapable of managing basic age appropriate skills</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_210" value="Is selectively mute">Is selectively mute</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_210" value="Other:">Other:<input class="cst_Other" name="CST_210_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_211" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_211" 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_211" value="Other:">Other:<input class="cst_Other" name="CST_211_Other" type="text"></label> </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">9. Does this child have significant problems managing their feelings?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_212" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_212" 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_212" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_212_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Severe temper tantrums; screams uncontrollably">Severe temper tantrums; screams uncontrollably</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Cries inconsolably">Cries inconsolably</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Significant and regular nightmares">Significant and regular nightmares</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Withdrawn and uninvolved with others">Withdrawn and uninvolved with others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Whines or pouts excessively">Whines or pouts excessively</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Regularly expresses the feeling that others are out to get him/her">Regularly expresses the feeling that others are out to get him/her</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Worries excessively and preoccupied compulsively with minor annoyances">Worries excessively and preoccupied compulsively with minor annoyances</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Regularly expresses feeling worthless or inferior">Regularly expresses feeling worthless or inferior</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Frequently appears sad or depressed">Frequently appears sad or depressed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_213" value="Constantly restless or overactive, etc.">Constantly restless or overactive, etc.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_213" value="Other:">Other:<input class="cst_Other" name="CST_213_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_214" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_214" 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_214" value="Other:">Other:<input class="cst_Other" name="CST_214_Other" type="text"></label> </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">10. Does this child have a history of psychiatric hospitalization, psychiatric care and/or prescribed psychotropic medication?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_215" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_215" 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_215" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_215_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_216" value="Child has a history of psychiatric care, either inpatient or outpatient.">Child has a history of psychiatric care, either inpatient or outpatient.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_216" value="Client is taking prescribed psychotropic medication.">Client is taking prescribed psychotropic medication.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_216" value="Other:">Other:<input class="cst_Other" name="CST_216_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_217" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_217" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_217" value="Other:">Other:<input class="cst_Other" name="CST_217_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">11. Is this child known to abuse* alcohol and/or drugs?</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_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_219" value="Child regularly uses alcohol.">Child regularly uses alcohol.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_219" value="Child regularly uses drugs. *It is NOT abuse if drug use is part of a religious practice or spiritual ceremony that is approved by tribal leaders or a medicine person and is a common practice in traditional ways.">Child regularly uses drugs. *It is NOT abuse if drug use is part of a religious practice or spiritual ceremony that is approved by tribal leaders or a medicine person and is a common practice in traditional ways.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_219" value="Other:">Other:<input class="cst_Other" name="CST_219_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_220" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_220" 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_220" value="Other:">Other:<input class="cst_Other" name="CST_220_Other" type="text"></label> </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">12. Has this child experienced abuse, neglect or abandonment in the last 90 days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_221" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_221" 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_221" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_221_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Subjected to the removal from their home">Subjected to the removal from their home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_222" value="Placed in alternative custody (i.e. relative home or shelter). ">Placed in alternative custody (i.e. relative home or shelter). </label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_222" value="Other:">Other:<input class="cst_Other" name="CST_222_Other" type="text"></label></li><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">Over 90 Days Ago?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_223" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_223" 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_223" value="Other:">Other:<input class="cst_Other" name="CST_223_Other" type="text"></label> </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">13. Has this child had a Forensic Interview at Childhaven?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_224" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_224" 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_224" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_224_Other" type="text"></label> </li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Select all that apply</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_225" value="In the last 3 months">In the last 3 months</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_225" value="In the last 6 months ">In the last 6 months </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_225" value="In the last 12 months">In the last 12 months</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_225" value="Over a year ago">Over a year ago</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_225" value="Other:">Other:<input class="cst_Other" name="CST_225_Other" type="text"></label></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of Interview (if known):</label><input class="cst_datepicker" name="CST_227" 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>SCHOOL INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">School Name/Address:</label><input name="CST_22" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Education"> <i class="fa fa-font"></i><label class="er_fld_label required">Grade:</label><input name="CST_23" type="text" class="er_fld_required"></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 required">IEP:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" 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_24" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_24_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">If Yes to IEP, provide details:</label><input name="CST_27" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Current school status:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Attending">Attending</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Suspended">Suspended</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Dropped/Withdrew">Dropped/Withdrew</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_25" value="Expelled">Expelled</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Can client attend school ASAP?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_26" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_26" 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_26" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_26_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">COMMENTS OR CONCERNS:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Paragraph</label><textarea name="CST_28" 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>INSURANCE INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Insurance Type:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Medicaid">Medicaid</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_31" value="Private Insurance">Private Insurance</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Managed Care Organization:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_30" value="BCBS">BCBS</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_30" value="Presbyterian">Presbyterian</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_30" value="Western Sky">Western Sky</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_30" value="Fee For Service">Fee For Service</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_30" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_30_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 required">Group or ID#:</label><input name="CST_33" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label required">SSN#:</label><input name="CST_34" 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">Eligibility Status:</label><input name="CST_35" 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>MENTAL HEALTH INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this child currently receive therapy, counseling, or pyschotherapy services?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_228" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_228" 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_228" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_228_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please indicate current provider, dates of service, and reason for moving services to Childhaven.</label><textarea name="CST_229" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has this child received therapy, counseling, or psychotherapy services in the past?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_230" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_230" 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_230" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_230_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please provide name of service provider or clinic and dates of service.</label><textarea name="CST_231" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this child currently receive medication management from a psychiatric provider?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_232" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_232" 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_232" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_232_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please provide the name and phone number of the pscyhiatric provider/clinic.</label><textarea name="CST_233" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does this child have a history of receiving medication management from a psychiatric provider?</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></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">If yes, please provide the name of the previous psychiatric provider, reason medications were stopped, and date when medication were stopped.</label><textarea name="CST_235" 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>MEDICAL INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Care Physician</label><input name="CST_36" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone #:</label><input name="CST_37" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Primary Care Physician Address:</label><input name="CST_38" type="text"></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">City:</label><input name="CST_40" 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">State:</label><input name="CST_39" 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">Zip Code:</label><input name="CST_41" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Emergency Contact Name:</label><input name="CST_44" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number:</label><input name="CST_45" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you authorize communication between your primary care physician and Childhaven?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="I DO authorize communication.">I DO authorize communication.</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_46" value="I DO NOT authorize communication.">I DO NOT authorize communication.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_46_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Do you authorize communication between your psychiatrist and Childhaven?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="I DO authorize communication.">I DO authorize communication.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="I DO NOT authorize communication.">I DO NOT authorize communication.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_48" value="Other:">Other:<input class="cst_Other" name="CST_48_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">Advanced Directives:</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">Advanced Directives are a document for individuals 18 years of age and older, in which you give instructions about your healthcare, what you want done or not done, if you cannot speak for yourself. Advanced directives have been explained to me and: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required"></label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="I have an Advanced Directive in place and have provided a copy to Childhaven.">I have an Advanced Directive in place and have provided a copy to Childhaven.</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="I would like information/forms on Advanced Directives.">I would like information/forms on Advanced Directives.</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="I choose not to receive information/forms on Advanced Directives.">I choose not to receive information/forms on Advanced Directives.</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="I am not 18 years of age or older.">I am not 18 years of age or older.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_50" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_50_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>MEDICATION/OTC/HERBAL/VITAMINS</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="No medications used at this time.">No medications used at this time.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_55" value="Other:">Other:<input class="cst_Other" name="CST_55_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">Name of Medication</label><input name="CST_53" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_52" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_51" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_54" type="text" class="er_fld_width100"></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 Medication</label><input name="CST_56" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_57" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_58" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_59" type="text" class="er_fld_width100"></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 Medication</label><input name="CST_60" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_61" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_62" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_63" type="text" class="er_fld_width100"></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 Medication</label><input name="CST_64" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_65" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_66" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_67" type="text" class="er_fld_width100"></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 Medication</label><input name="CST_68" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_69" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_70" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_71" type="text" class="er_fld_width100"></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 Medication</label><input name="CST_72" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage/Frequency</label><input name="CST_73" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Reason</label><input name="CST_74" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Side Effects</label><input name="CST_75" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Allergies/significant medical conditions/chronic illnesses:</label><input name="CST_76" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Medical/Dental issues that require immediate attention:</label><input name="CST_77" 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>RESPONSIBLE PARTY INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Legal Guardian:</label><input name="CST_78" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship to Client:</label><input name="CST_79" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address (if different from client's address)</label><input name="CST_80" type="text"></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">City</label><input name="CST_82" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_81" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_83" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_125" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Home or Cell #</label><input name="CST_84" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone #</label><input name="CST_85" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Employer Name</label><input name="CST_86" type="text" class="er_fld_width100 er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employer Address</label><input name="CST_87" type="text"></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">City</label><input name="CST_88" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_89" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_90" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false" map_to="CustomField_Value_3"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Decision-Making Authority for Child</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="Mother Only">Mother Only</label><label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="Father Only">Father Only</label><label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="Shared Decision-Making">Shared Decision-Making</label><label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="Other Relative">Other Relative</label><label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="CYFD">CYFD</label><label class="er_option"><input class="type_radio" type="radio" name="CST_183" value="Tribal Social Services">Tribal Social Services</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_183" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_183_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Mother's Name</label><input name="CST_91" type="text" class="er_fld_width100 er_fld_required"></li><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Natural">Natural</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Adoptive">Adoptive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Step">Step</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Foster">Foster</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_93" value="Other:">Other:<input class="cst_Other" name="CST_93_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB</label><input name="CST_104" type="text" class="er_fld_width50"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">SSN</label><input name="CST_105" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address (if different from client's address)</label><input name="CST_92" type="text"></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">City</label><input name="CST_94" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_95" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_96" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_124" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Home or Cell #</label><input name="CST_97" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone #</label><input name="CST_98" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employer Name</label><input name="CST_99" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employer Address</label><input name="CST_100" type="text" class="er_fld_width100"></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">City</label><input name="CST_101" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_102" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_103" type="text" class="er_fld_width100"></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Marital Status</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_106" value="Married">Married</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_106" value="Single">Single</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_106" value="Divorced">Divorced</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_106" value="Separated">Separated</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_106" value="Widowed">Widowed</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_106" value="Other:">Other:<input class="cst_Other" name="CST_106_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Father's Name</label><input name="CST_107" type="text" class="er_fld_width100 er_fld_required"></li><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="Natural">Natural</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="Adoptive">Adoptive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="Step">Step</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_108" value="Foster">Foster</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_108" value="Other:">Other:<input class="cst_Other" name="CST_108_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB</label><input name="CST_109" type="text" class="er_fld_width50"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">SSN</label><input name="CST_110" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address (if different from client's address)</label><input name="CST_111" type="text"></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">City</label><input name="CST_112" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_113" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_114" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_123" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Home or Cell #</label><input name="CST_115" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Work Phone #</label><input name="CST_116" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employer Name</label><input name="CST_117" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employer Address</label><input name="CST_118" type="text" class="er_fld_width100"></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">City</label><input name="CST_119" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_120" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_121" type="text" class="er_fld_width100"></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Marital Status</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_122" value="Married">Married</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_122" value="Single ">Single </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_122" value="Divorced">Divorced</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_122" value="Separated">Separated</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_122" value="Widowed">Widowed</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_122" value="Other:">Other:<input class="cst_Other" name="CST_122_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>OTHER CONTACTS</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Stepparent (s)</label><input name="CST_127" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone #</label><input name="CST_128" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label">Email address</label><input name="CST_129" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Foster/Adoptive Parent(s)</label><input name="CST_130" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone #</label><input name="CST_131" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_132" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">JPO</label><input name="CST_133" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone #</label><input name="CST_134" type="text" class="er_fld_width100"></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">Email Address</label><input name="CST_141" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Social Worker</label><input name="CST_135" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone #</label><input name="CST_136" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_137" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Agency</label><input name="CST_138" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">Title</label><input name="CST_139" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please check all the ways we may contact you</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_140" value="Call Home">Call Home</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_140" value="Call Work">Call Work</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_140" value="Cell: Call or Text">Cell: Call or Text</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_140" value="Email">Email</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_140" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_140_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col4" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Can we identify ourselves as Childhaven if we call you?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_142" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_142" 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_142" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_142_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">HOUSEHOLD COMPOSITION</div></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">Name</label><input name="CST_143" type="text" class="er_fld_width100 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">Age</label><input name="CST_144" type="text" class="er_fld_width100 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">Gender</label><input name="CST_145" type="text" class="er_fld_width100 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">Relationship</label><input name="CST_155" type="text" class="er_fld_width100 er_fld_required"></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">Name</label><input name="CST_146" type="text" class="er_fld_width100 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">Age</label><input name="CST_147" type="text" class="er_fld_width100 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">Gender</label><input name="CST_148" type="text" class="er_fld_width100 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">Relationship</label><input name="CST_156" type="text" class="er_fld_width100 er_fld_required"></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">Name</label><input name="CST_149" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Age</label><input name="CST_150" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_151" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_157" type="text" class="er_fld_width100"></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">Name</label><input name="CST_152" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Age</label><input name="CST_153" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_154" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_158" type="text" class="er_fld_width100"></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">Name</label><input name="CST_159" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Age</label><input name="CST_160" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_161" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_162" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Household Income per Month</label><input name="CST_163" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Assistance</label><input name="CST_164" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">Responsible Party</label><input name="CST_165" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>REASON CHILD IS IN NEED OF SERVICES</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space:normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Choose all that apply</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Neglect">Neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Runaway/Homeless Youth">Runaway/Homeless Youth</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Adult Arrested - DV">Adult Arrested - DV</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Suspected Physical Abuse">Suspected Physical Abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Disrupted Foster Home">Disrupted Foster Home</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Adult Arrested - Alcohol or Drugs">Adult Arrested - Alcohol or Drugs</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Suspected Sexual Abuse">Suspected Sexual Abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Witness of Crime">Witness of Crime</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Child- Alcohol or Drugs">Child- Alcohol or Drugs</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Court Order">Court Order</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Family Problems">Family Problems</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_167" value="Mental Health Issues">Mental Health Issues</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_167" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_167_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">Brief Description</label><input name="CST_168" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false"> <i class="fa fa-font"></i><label class="er_fld_label required">Physical or Sexual Abuse (if yes, by whom and when?)</label><input name="CST_169" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Has this been reported to Law Enforcement?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_171" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_171" 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_171" value="Other:">Other:<input class="cst_Other" name="CST_171_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.333333333333336%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Was a Forensic Interview conducted?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_172" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_172" 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_172" value="Other:">Other:<input class="cst_Other" name="CST_172_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, when?</label><input name="CST_173" type="text"></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>Authorization for Release of Protected Information and Signatures</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">Written Authorization (complete only if you are the client's legal guardian): I, the client's legal guardian, agree to release the information on this form to Childhaven, Inc. This information will be used to determine which services are required. I understand that I may cancel this authorization at any time by submitting a written request to Childhaven, except where a disclosure has already been made in reliance on my prior authorization. By signing below you agree to the best of your knowledge you have advised Childhaven of all medical/mental issues of which you are aware. If any issues arise that might affect the safety or well-being of this child/youth or any other clients/staff in this facility it could cause immediate removal from certain services.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Legal Guardian Name</label><input name="CST_184" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship to Client</label><input name="CST_186" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 33.3333%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Legal Guardian</label><div class="cst_signaturepad"></div><input name="CST_174" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date</label><input class="cst_datepicker er_fld_width25 er_fld_required" name="CST_177" type="text" value="11/9/2024"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-pencil"></i><label class="er_fld_label">Client Signature (14+ years old)</label><div class="cst_signaturepad"></div><input name="CST_175" type="text"><button class="type_button" disabled="">Clear Signature</button></li><li class="er_fld_type_date" draggable="false" style="width: 33.333333333333336%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_width25" name="CST_176" type="text"></li></ul>
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