Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Thank you for the consideration of Cherokee Home for Children. Please understand that Cherokee Home is a basic level of care program. We cannot provide services for youth with addictions, youth that are abusive, consistently runaway, have committed sexual assault or any other extreme behaviors that require a higher level of care than basic needs. Please fill out the application to the best of your ability. The information you provide contributes to the consideration of possible placement. If you have any questions, just call 325-622-4201 or 1-800-689-3292. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of person filling out the questionnaire</label><input name="CST_1" 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_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship to Youth</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_10" type="text" class="er_fld_width100 er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_12" 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: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Childs Legal Status (person who has rights/managing conservator)</label><input name="CST_54" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">YOUTH INFORMATION</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_24" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 20%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Age</label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_8" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_8" value="Female">Female</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_8" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_8_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 required">Mailing Address</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_9" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Brief Description for Need of Placement</label><textarea name="CST_23" style="width:100%;" class="er_fld_required"></textarea></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 required">Appropriate Behaviors</label><textarea name="CST_53" style="width:100%;" class="er_fld_required"></textarea></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">What special skills or interest does the child have?</label><textarea name="CST_97" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><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">Check all the describe the youth:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Unable to share">Unable to share</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Has a strong desire for sameness and routine">Has a strong desire for sameness and routine</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Uncooperative with others">Uncooperative with others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Authority conflicts with others">Authority conflicts with others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Has strong outbursts of anger">Has strong outbursts of anger</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Tends to crave attention">Tends to crave attention</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="No real relationships with others">No real relationships with others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Seems sensitive to criticism, lacking in self confidence">Seems sensitive to criticism, lacking in self confidence</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Isolates self away from family">Isolates self away from family</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Needs encouragement to take part in new situations">Needs encouragement to take part in new situations</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Spends little time at home">Spends little time at home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Trouble getting along with other children">Trouble getting along with other children</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Fights with brothers and/or sisters">Fights with brothers and/or sisters</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Tends to be active and aggressive or assaultive">Tends to be active and aggressive or assaultive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Child rarely brings friends home">Child rarely brings friends home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Tends to be heedless, lack carefulness, be impulsive">Tends to be heedless, lack carefulness, be impulsive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_92" value="Runs away from home">Runs away from home</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_92" value="Other:">Other:<input class="cst_Other" name="CST_92_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">(cont)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Tends to get over excited in play with other children">Tends to get over excited in play with other children</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Talks about hurting self or others">Talks about hurting self or others</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Parents have met most of our child’s friends">Parents have met most of our child’s friends</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Destroys property">Destroys property</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Family unaware of what child is doing when not home">Family unaware of what child is doing when not home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Runs away from home">Runs away from home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Evasive/hostile when questioned about activities">Evasive/hostile when questioned about activities</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Sexual misbehavior">Sexual misbehavior</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Cruel to animals">Cruel to animals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Steals">Steals</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Lies">Lies</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Disobeys curfew">Disobeys curfew</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Self destructive">Self destructive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Alcohol usage">Alcohol usage</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Drug usage">Drug usage</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Uses profane language">Uses profane language</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_93" value="Prefers to play alone/does not make friends easily">Prefers to play alone/does not make friends easily</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_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Comments for behaviors checked above:</label><textarea name="CST_94" style="width:100%;"></textarea></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">Has youth ever been in CPS care?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_36" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_36" 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_36" value="Other:">Other:<input class="cst_Other" name="CST_36_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_36" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for CPS Care:</label><textarea name="CST_95" style="width:100%;"></textarea></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">Is youth adopted?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_37" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_37" 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_37" value="Other:">Other:<input class="cst_Other" name="CST_37_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_37" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason and length for adoption:</label><textarea name="CST_96" 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">Has Child ever been arrested? on probation?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_117" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_117" 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_117" value="Other:">Other:<input class="cst_Other" name="CST_117_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_117" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for arrest? Probation?</label><textarea name="CST_118" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">FAMILY HISTORY</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">Pleasegive names and describe relationship with birth parent(s). (past, present, quality, etc.)</label><textarea name="CST_60" style="width:100%;"></textarea></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 Applicable, please give names and describe relationship with current parent(s). (past, present, quality, etc.)</label><textarea name="CST_61" style="width:100%;"></textarea></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 Applicable, please give names, age, and describe relationship (s) with past or current siblings. </label><textarea name="CST_62" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Does the youth have any relationship with other signficant adults or youth?</label><select name="CST_63" class="er_fld_width75"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe that relationship:</label><textarea name="CST_64" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe the child's current home environment and family functioning:</label><textarea name="CST_98" style="width:100%;"></textarea></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">Has the child ever lived outside of the home or been hospitalized?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_99" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_99" 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_99" value="Other:">Other:<input class="cst_Other" name="CST_99_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_99" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for outside placement:</label><textarea name="CST_100" style="width:100%;"></textarea></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">How has child been disciplined?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="time out">time out</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="chores">chores</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="grounding">grounding</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="loss of privilege">loss of privilege</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="early bedtime">early bedtime</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="spanking">spanking</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_103" value="logical consequences">logical consequences</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_103" value="Other:">Other:<input class="cst_Other" name="CST_103_Other" type="text"></label></li><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">Please describe discipline: (who disciplines, when, how often, child's response)</label><textarea name="CST_104" style="width:100%;"></textarea></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">How does the current family plan to be involved while the youth is in placement? (phone calls, visits, etc.)</label><textarea name="CST_101" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">CHILD EDUCATION</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text sortable-chosen" draggable="true" style="width: 20%;" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label">Current School and Dates Attended</label><input name="CST_14" type="text"></li><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 20%;" map_to="CC_School_City"> <i class="fa fa-font"></i><label class="er_fld_label">School City and State</label><input name="CST_15" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_Grade"> <i class="fa fa-font"></i><label class="er_fld_label">Grade Level</label><input name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe school behaviors and issues:</label><textarea name="CST_102" style="width:100%;"></textarea></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">Suspensions?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_22" 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_22" value="Other:">Other:<input class="cst_Other" name="CST_22_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for suspensions:</label><textarea name="CST_106" style="width:100%;"></textarea></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">Please describe child's academic and any deficits or difficulties:</label><textarea name="CST_107" 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">What the future educational goals?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_108" value="HS/GED">HS/GED</label><label class="er_option"><input class="type_radio" type="radio" name="CST_108" value="College/University">College/University</label><label class="er_option"><input class="type_radio" type="radio" name="CST_108" value="Trade/Technical School">Trade/Technical School</label><label class="er_option"><input class="type_radio" type="radio" name="CST_108" value="Military">Military</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" 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_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_School_SpecialEd"><i class="fa fa-circle-o"></i><label class="er_fld_label">Special Education?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_19" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_19" 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_19" value="Other:">Other:<input class="cst_Other" name="CST_19_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_19" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Services Provided:</label><textarea name="CST_105" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">CHILD HEALTH INFORMATION</div></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">Were there any complications with child's pregnancy or birth?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_121" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_121" 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_121" value="Other:">Other:<input class="cst_Other" name="CST_121_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe child's early childhood development:</label><textarea name="CST_122" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><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 Last Well Child Exam:</label><input class="cst_datepicker" name="CST_123" type="text"></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 last Dental exam:</label><input class="cst_datepicker" name="CST_124" type="text"></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">Are immunizations up to date? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_125" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_125" 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_125" value="Other:">Other:<input class="cst_Other" name="CST_125_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">Has youth had a psychological evaluation?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_52" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_52" 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_52" value="Other:">Other:<input class="cst_Other" name="CST_52_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">List Any Medical Diagnosis</label><input name="CST_34" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Is the child considered a danger to self?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_113" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_113" 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_113" value="Other:">Other:<input class="cst_Other" name="CST_113_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_113"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe suicidal incidents:</label><textarea name="CST_115" style="width:100%;"></textarea></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">Is the child considered a danger to others?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_114" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_114" 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_114" value="Other:">Other:<input class="cst_Other" name="CST_114_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe the danger:</label><textarea name="CST_116" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Current Medication(s)</label><input name="CST_27" 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">Reason for Medication(s)</label><input name="CST_28" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Medical Insurance</label><select name="CST_30" class=""><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Medicaid">Medicaid</option><option value="CHIPS">CHIPS</option><option value="Private">Private</option><option value="None">None</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Allergies?</label><input name="CST_31" type="text" class=""></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">Does child wet or soil the bed?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_109" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_109" 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_109" value="Other:">Other:<input class="cst_Other" name="CST_109_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_109" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe and list any medications:</label><textarea name="CST_110" 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">Is child sexually active?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_111" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_111" 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_111" value="Other:">Other:<input class="cst_Other" name="CST_111_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_111" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Have they been tested for STD/Pregancy? Results?</label><textarea name="CST_112" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><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">Abuse?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Sexual Abuse">Sexual Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Emotional Abuse">Emotional Abuse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Neglect">Neglect</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Abandonment">Abandonment</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_32" value="Other:">Other:<input class="cst_Other" name="CST_32_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_medium er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Physical+Abuse&er_fld_showif_values=Sexual+Abuse&er_fld_showif_values=Emotional+Abuse&er_fld_showif_values=Neglect&er_fld_showif_values=Abandonment"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please provide information regarding the abuse:</label><textarea name="CST_55" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><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">Substance Abuse by Youth?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Alcohol">Alcohol</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Tobacco Products">Tobacco Products</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Cocaine/Crack">Cocaine/Crack</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Marijuana">Marijuana</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Inhalants/Vaping">Inhalants/Vaping</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Methamphetamine">Methamphetamine</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Prescription Drugs">Prescription Drugs</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_33" value="Other:">Other:<input class="cst_Other" name="CST_33_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_medium" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_33" er_fld_condvals="er_fld_showif_values=Alcohol&er_fld_showif_values=Tobacco+Products&er_fld_showif_values=Cocaine%2FCrack&er_fld_showif_values=Marijuana&er_fld_showif_values=Inhalants%2FVaping&er_fld_showif_values=Methamphetamine&er_fld_showif_values=Prescription+Drugs"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe substance abuse:</label><textarea name="CST_56" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please list and explain the events and/or losses that could have had a traumatic/negative impact on the child. (i.e. any abuse, loss of family member, divorce, alcohol/drug abuse, imprisonments etc.)</label><textarea name="CST_119" style="width:100%;"></textarea></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">Does youth know you are seeking placement?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_41" 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_41" value="Other:">Other:<input class="cst_Other" name="CST_41_Other" type="text"></label> </li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Does youth desire placement?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_40" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_40" 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_40" value="Other:">Other:<input class="cst_Other" name="CST_40_Other" type="text"></label> </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">Youth's Church Preference</label><input name="CST_42" 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">Current Church Name and Location</label><input name="CST_43" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">What are your expectations of youth's placement?</label><textarea name="CST_48" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Any other information you would like us to know?</label><textarea name="CST_51" style="width:100%;"></textarea></li></ul>
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