Online Referral
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<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: 33.3333%;" 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><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">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: 33.3333%;" 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><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile"> <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: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Preferred Method of Contact (Phone, Email, Text)</label><input name="CST_17" type="text" value="Phone, Email, Text" class="er_fld_required"></li><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/Area You Live In</label><input name="CST_10" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_selected" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Household 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">Are you a parent/caregiver/guardian?</label><input name="CST_20" type="text" value="Parent/Caregiver/Guardian?"></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">Number of children in the home</label><input name="CST_21" type="text"></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Age range of children</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="0–5">0–5</label><label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="6–10">6–10</label><label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="11–14">11–14</label><label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="15–18">15–18</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_22" value="Other:">Other:<input class="cst_Other" name="CST_22_Other" type="text"></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 required">Services of Interest (check all that apply)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Family Coaching / Parenting Support">Family Coaching / Parenting Support</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="STRONG Families">STRONG Families</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Youth Mentoring">Youth Mentoring</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Support for behavioral or emotional challenges">Support for behavioral or emotional challenges</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Faith-based mentoring opportunities">Faith-based mentoring opportunities</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Not sure / would like to talk with someone">Not sure / would like to talk with someone</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_13" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_13_Other" type="text"></label></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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Additional Information (Optional)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" map_to="CC_Comments" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please provide a brief description of the support you are seeking.</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">How soon they would like someone to contact them</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="ASAP">ASAP</label><label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="Within a few days">Within a few days</label><label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="Just gathering information">Just gathering information</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_23" value="Other:">Other:<input class="cst_Other" name="CST_23_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_ReferralSource_Ref" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about us?</label><select name="CST_15" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Internet Search (Google, Bing, etc.)">Internet Search (Google, Bing, etc.)</option><option value="Church or Faith Community">Church or Faith Community</option><option value="Friend or Family Member">Friend or Family Member</option><option value="Community Event">Community Event</option><option value="Christian Family Care Website">Christian Family Care Website</option><option value="Healthcare Provider">Healthcare Provider</option><option value="Current or Former Client">Current or Former Client</option><option value="Staff Member">Staff Member</option><option value="Email">Email</option><option value="Partner Organization">Partner Organization</option><option value="Other">Other</option><option value=""></option></select></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">Consent</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="May Christian Family Care contact you?">May Christian Family Care contact you?</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_11" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_11_Other" type="text"></label></li></ul>
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