Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content er_fld_selected" 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 fill out the questionaire to the best of your ability and 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">Email</label><input name="CST_12" type="text" class="er_fld_width100"></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>Youth Information</label><hr></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_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_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></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label">Current School</label><input name="CST_14" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_City"> <i class="fa fa-font"></i><label class="er_fld_label">School City </label><input name="CST_15" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_State"> <i class="fa fa-font"></i><label class="er_fld_label">School State</label><input name="CST_25" 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_radio" style="white-space: normal; width: 25%;" 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_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Behavior Issues at School</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_20" 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_20" value="Other:">Other:<input class="cst_Other" name="CST_20_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">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_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Suicidal Ideations?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_39" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_39" 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_39" value="Other:">Other:<input class="cst_Other" name="CST_39_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">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: 50%;"> <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_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: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Medical Insurance</label><select name="CST_30" class="er_fld_required"><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: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Allergies?</label><input name="CST_31" 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">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_checkbox" style="white-space: normal; width: 50%;" 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></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">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: 50%;" 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: 50%;"> <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: 50%;"> <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_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Minister's Name</label><input name="CST_44" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_45" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style=""> <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=""> <i class="fa fa-paragraph"></i><label class="er_fld_label">What changes would you like to see in youth?</label><textarea name="CST_49" 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=""> <i class="fa fa-paragraph"></i><label class="er_fld_label">What changes would you like to see in the youth's family?</label><textarea name="CST_50" 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=""> <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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