Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 33.3333%;"><i class="fa fa-header"></i><label>Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address:</label><input name="CST_9" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Best Contact Phone</label><input name="CST_7" type="text" class="er_fld_required er_fld_width100" value="(xxx) xxx-xxxx"></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">Address Line 1</label><input name="CST_27" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address Line 2</label><input name="CST_28" type="text"></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_29" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Address_State"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">State</label><select name="CST_12" class="er_fld_required er_fld_width100"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona" selected="">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></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_30" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 100%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_31" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Preferred method of contact:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Phone Call">Phone Call</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Email">Email</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Text">Text</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_18" value="Other:">Other:<input class="cst_Other" name="CST_18_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">(Please check all that apply. By checking the boxes below you are indicating a team member may contact you via each method of communication checked)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_pagebreak" draggable="false" style="width: 50%;"><i class="fa fa-cut"></i><label>Page Break</label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">I live closest to the _____ AFC counseling office</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Phoenix">Phoenix</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Tucson">Tucson</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Prescott">Prescott</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_25" value="Other:">Other:<input class="cst_Other" name="CST_25_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Additional Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" map_to="CC_Comments" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Briefly summarize the reason you are seeking services or more information:</label><textarea name="CST_3" style="width:100%;" class="er_fld_width100"></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">Are you seeking drug/alcohol treatment?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_5" 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_5" value="Other:">Other:<input class="cst_Other" name="CST_5_Other" type="text"></label> </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">Are you seeking services at the recommendation of the court or legal entity?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_4" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_4" 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_4" value="Other:">Other:<input class="cst_Other" name="CST_4_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Do you have a preferred counselor or coach? (Leave blank if no)</label><input name="CST_19" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Preferred insurance or payment method</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_32" value="Private Pay">Private Pay</label><label class="er_option"><input class="type_radio" type="radio" name="CST_32" value="AHCCCS(Maricopa County residents only)">AHCCCS(Maricopa County residents only)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_32" value="Unsure">Unsure</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_32" value="Other:">Other:<input class="cst_Other" name="CST_32_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature"> <i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_20" type="text"><button class="type_button" disabled="">Clear Signature</button></li></ul>
Submit