Online Referral

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: 50%;"><i class="fa fa-header"></i><label>Texas Girls &amp; Boys Ranch Counseling Services Application</label><hr></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>Child Information</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">Please complete the following information on your child.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_First">
<i class="fa fa-font"></i><label class="er_fld_label required">Child First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_Middle">
<i class="fa fa-font"></i><label class="er_fld_label required">Child Middle Name</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_Last">
<i class="fa fa-font"></i><label class="er_fld_label required">Child Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_Street_1">
<i class="fa fa-font"></i><label class="er_fld_label required">Street Address</label><input name="CST_42" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Address_City" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_43" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Address_State" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_44" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" map_to="CC_Address_Zip" style="width: 20%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip</label><input name="CST_46" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Phone_Home" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Home Phone</label><input name="CST_13" type="text"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Phone_Mobile" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Mobile Phone</label><input name="CST_14" 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_DOB">
<i class="fa fa-font"></i><label class="er_fld_label required">Date of Birth</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_SSN" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Social Security Number</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Gender" style="width: 33.3333%;">
<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="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_text" draggable="false" map_to="CC_Medicaid" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Medicaid Number</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Race" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_8" class="er_fld_required"><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Ethnicity</label><select name="CST_9" class="er_fld_required"><option value="Hispanic/Latino">Hispanic/Latino</option><option value="Non-Hispanic or Latino">Non-Hispanic or Latino</option><option value="Multi-Race/Multi-Ethnicity ">Multi-Race/Multi-Ethnicity </option><option value="Prefer Not to Answer">Prefer Not to Answer</option></select></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">Type of Placement</label><select name="CST_12" class="er_fld_required"><option value="Foster">Foster</option><option value="Foster to Adopt">Foster to Adopt</option><option value="Adoptive">Adoptive</option><option value="Kinship">Kinship</option><option value="Other">Other</option></select></li><li class="er_fld_type_date" draggable="false" style="width: 50%;">
<i class="fa fa-calendar"></i><label class="er_fld_label">Date of Placement</label><input class="cst_datepicker" name="CST_10" type="text"></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">Reason(s) for referral (check all that apply):</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Sexual Abuse (Alleged/Reported)">Sexual Abuse (Alleged/Reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Physical Abuse (Alleged/Reported)">Physical Abuse (Alleged/Reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Neglect (Alleged/Reported)">Neglect (Alleged/Reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Emotional Abuse (Alleged/Reported)">Emotional Abuse (Alleged/Reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Domestic Violence">Domestic Violence</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Incarceration of Parent(s)">Incarceration of Parent(s)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Drug Abuse (Parent)">Drug Abuse (Parent)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Drug Abuse (Child)">Drug Abuse (Child)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Death of Parent(s)">Death of Parent(s)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_15" value="Child�s Behavior Problems">Child�s Behavior Problems</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_15" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_15_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>Caregiver(s) and Family Information</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">Please complete the following information on primary caregiver.  </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">Parent First Name</label><input name="CST_28" 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">Parent Last Name</label><input name="CST_29" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;">
<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_27" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_30" class="er_fld_required"><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_31" class="er_fld_required"><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Ethnicity</label><select name="CST_32" class="er_fld_required"><option value="Hispanic/Latino">Hispanic/Latino</option><option value="Non-Hispanic or Latino">Non-Hispanic or Latino</option><option value="Multi-Race/Multi-Ethnicity ">Multi-Race/Multi-Ethnicity </option><option value="Prefer Not to Answer">Prefer Not to Answer</option></select></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">Highest level of education completed</label><select name="CST_137" class="er_fld_required"><option value="Eighth grade or less ">Eighth grade or less </option><option value="Some high school">Some high school</option><option value="High school diploma">High school diploma</option><option value="GED">GED</option><option value="Some college">Some college</option><option value="2 to 4 year college degree">2 to 4 year college degree</option><option value="Post graduate">Post graduate</option><option value="Other">Other</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">Occupation</label><input name="CST_34" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Work Schedule</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Part time">Part time</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Full time">Full time</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Flexible">Flexible</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Daytime">Daytime</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Evening">Evening</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Weekend">Weekend</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Weekdays">Weekdays</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Schedule varies">Schedule varies</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_36" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_36_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 required">Typical Hours:</label><input name="CST_37" type="text" class="er_fld_required"></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 required">Relationship Status</label><select name="CST_38" class="er_fld_required"><option value="Single, never married">Single, never married</option><option value="Married">Married</option><option value="Separated">Separated</option><option value="Divorced">Divorced</option><option value="Partnered">Partnered</option><option value="Widowed">Widowed</option><option value="Other">Other</option></select></li><li class="er_fld_type_number er_fld_showif" draggable="false" er_fld_condfld="CST_38" er_fld_condvals="er_fld_showif_values=Married" style="width: 33.3333%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">If married, number of years:</label><input name="CST_39" type="text" class="er_fld_required"></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">Is the parent/caregiver biologically related to the child?</label><select name="CST_40" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">What is the caregiver/parent's relationship to the child?</label><select name="CST_41" class="er_fld_required"><option value="Biological Parent">Biological Parent</option><option value="Foster Parent">Foster Parent</option><option value="Grandparent" selected="">Grandparent</option><option value="Aunt/ Uncle">Aunt/ Uncle</option><option value="Sibling">Sibling</option><option value="Cousin">Cousin</option><option value="Other">Other</option></select></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">Parent First Name</label><input name="CST_47" 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">Parent Last Name</label><input name="CST_48" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;">
<i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth</label><input class="cst_datepicker" name="CST_49" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Gender</label><select name="CST_50"><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Race</label><select name="CST_51"><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Ethnicity</label><select name="CST_52"><option value="Hispanic/Latino">Hispanic/Latino</option><option value="Non-Hispanic or Latino">Non-Hispanic or Latino</option><option value="Multi-Race/Multi-Ethnicity ">Multi-Race/Multi-Ethnicity </option><option value="Prefer Not to Answer">Prefer Not to Answer</option></select></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">Highest level of education completed</label><select name="CST_53"><option value="Eighth grade or less ">Eighth grade or less </option><option value="Some high school">Some high school</option><option value="High school diploma">High school diploma</option><option value="GED">GED</option><option value="Some college">Some college</option><option value="2 to 4 year college degree">2 to 4 year college degree</option><option value="Post graduate">Post graduate</option><option value="Other">Other</option></select></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">Occupation</label><input name="CST_54" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Work Schedule </label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Part time">Part time</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Full time">Full time</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Flexible">Flexible</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Daytime">Daytime</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Evening">Evening</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Weekend">Weekend</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Weekdays">Weekdays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Schedule varies">Schedule varies</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><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Typical Hours</label><input name="CST_56" 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">Is the caregiver/parent biologically related to the child?</label><select name="CST_57"><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label">What is the caregiver/parent's relationship to the child?</label><select name="CST_58"><option value="Biological Parent">Biological Parent</option><option value="Foster Parent">Foster Parent</option><option value="Grandparent" selected="">Grandparent</option><option value="Aunt/ Uncle">Aunt/ Uncle</option><option value="Sibling">Sibling</option><option value="Cousin">Cousin</option><option value="Other">Other</option></select></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">Please provide information on others residing in the home.</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">Name</label><input name="CST_59" 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">Relationship</label><input name="CST_60" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_61" 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">Name</label><input name="CST_62" 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">Relationship</label><input name="CST_63" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_64" 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">Name</label><input name="CST_65" 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">Relationship</label><input name="CST_66" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_67" 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">Name</label><input name="CST_68" 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">Relationship</label><input name="CST_69" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_70" 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">Name</label><input name="CST_71" 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">Relationship</label><input name="CST_72" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_73" 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">Name</label><input name="CST_74" 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">Relationship</label><input name="CST_75" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_76" 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">Name</label><input name="CST_77" 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">Relationship</label><input name="CST_78" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_79" 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">Name</label><input name="CST_80" 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">Relationship</label><input name="CST_81" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_82" type="text"></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">Please provide information on other family members NOT residing in the home 
(including biological family members if child is placed in foster care).</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">Name</label><input name="CST_83" 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">Relationship</label><input name="CST_84" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_85" 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">Name</label><input name="CST_86" 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">Relationship</label><input name="CST_87" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_88" 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">Name</label><input name="CST_89" 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">Relationship</label><input name="CST_90" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_91" 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">Name</label><input name="CST_92" 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">Relationship</label><input name="CST_93" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_94" 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">Name</label><input name="CST_95" 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">Relationship</label><input name="CST_96" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_97" 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>Referral </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">Please provide information on the reason(s) for referral/ presenting problems.</div></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">How did you hear about our services?</label><select name="CST_102" class="er_fld_required"><option value="TxGBR Program/ Staff Member">TxGBR Program/ Staff Member</option><option value="Saint Francis">Saint Francis</option><option value="Facebook/ Social Media">Facebook/ Social Media</option><option value="Word of mouth">Word of mouth</option><option value="Other">Other</option></select></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">Family's View (What is going on now, what does the family want, goals for treatment, what are the needs of the family, etc.)</label><textarea name="CST_98" 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">Child's view (what does the child want/ need, goals for treatment)</label><textarea name="CST_99" style="width:100%;" class="er_fld_required"></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>Strengths</label><hr></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">Family Strengths</label><textarea name="CST_100" 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">Child Strengths</label><textarea name="CST_101" style="width:100%;" class="er_fld_required"></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>Development</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">Please provide information on the child's developmental history.</div></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 required">Prenatal Drug/ Alcohol Exposure?</label><select name="CST_103" class="er_fld_required"><option value="Confirmed">Confirmed</option><option value="Suspected">Suspected</option><option value="Unknown">Unknown</option><option value="None">None</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Time in foster care prior to placement in your home</label><select name="CST_105" class="er_fld_required"><option value="NA">NA</option><option value="1 year">1 year</option><option value="2 years">2 years</option><option value="3 years">3 years</option><option value="4 years">4 years</option><option value="5 years">5 years</option><option value="6 or more years">6 or more years</option></select></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">Prenatal Experience of Mother (maternal living situation, level of maternal stress, health during pregnancy, use of prescription/ non-prescription drugs, significant medical history/ events, etc)</label><textarea name="CST_104" 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">Infancy (living situation, emotional experience, support system, clarification on primary caretaker, any separations, major life events, significant medical history/events)</label><textarea name="CST_106" 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">Preschool (family situation, stress level, primary caretaker, daycare arrangements, adjustment to caretaker or new siblings, toileting, sleep routine, behavioral issues, major life events, significant medical history/events)</label><textarea name="CST_107" 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">School Age (family situation, adjustment to school, peer relationships, schools attended, reason for leaving schools, major life events, significant medical history/events)</label><textarea name="CST_108" style="width:100%;" class="er_fld_required"></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</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">Please tell us about your child's medical history.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does your child have any diagnosis/ medical conditions? Please select all that apply.</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="ADHD">ADHD</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Allergies">Allergies</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Anaphylaxis/ Epi Pen">Anaphylaxis/ Epi Pen</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Anxiety">Anxiety</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Asthma">Asthma</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Cancer">Cancer</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Depression">Depression</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Epilepsy/ Seizure Disorder">Epilepsy/ Seizure Disorder</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_148" value="Heart Disease">Heart Disease</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_148" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_148_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 required">Are there any other medical issues we need to be aware of?  Please share below.</label><textarea name="CST_150" style="width:100%;" class="er_fld_required"></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>Current Functioning</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">Please provide information on the child's current functioning (Home, School, and Community).</div></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">Child's Current School</label><input name="CST_109" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Child's Current Grade</label><select name="CST_110" class="er_fld_required"><option value="Daycare" selected="">Daycare</option><option value="Pre-K">Pre-K</option><option value="Kindergarten">Kindergarten</option><option value="1st Grade">1st Grade</option><option value="2nd Grade">2nd Grade</option><option value="3rd Grade">3rd Grade</option><option value="4th Grade">4th Grade</option><option value="5th Grade">5th Grade</option><option value="6th Grade">6th Grade</option><option value="7th Grade">7th Grade</option><option value="8th Grade">8th Grade</option><option value="Freshman">Freshman</option><option value="Sophomore">Sophomore</option><option value="Junior">Junior</option><option value="Senior">Senior</option><option value="ASD">ASD</option><option value="SCI">SCI</option><option value="SXI">SXI</option><option value="High School Graduate">High School Graduate</option><option value="GED">GED</option><option value="College">College</option><option value="None">None</option></select></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 required">Does the child currently have an Individualized Education Program (IEP)?</label><select name="CST_111" class="er_fld_required"><option value="Yes" selected="">Yes</option><option value="No">No</option><option value="Don't Know">Don't Know</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_111" er_fld_condvals="er_fld_showif_values=Yes" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">If yes, primary disability:</label><input name="CST_112" type="text" class="er_fld_required"></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">Does the child need an Individualized Education Program (IEP)?</label><select name="CST_113" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option><option value="Don't Know">Don't Know</option></select></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 required">Does the child currently have a 504 plan?</label><select name="CST_114" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option><option value="Don't Know">Don't Know</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the child need to have a 504 plan?</label><select name="CST_115" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option><option value="Don't Know">Don't Know</option></select></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">What type of classroom setting is the child in?</label><select name="CST_116" class="er_fld_required"><option value="Regular education">Regular education</option><option value="Self-contained">Self-contained</option><option value="Resource">Resource</option><option value="Other">Other</option></select></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">How much interest does the child have in learning?</label><select name="CST_117" class="er_fld_required"><option value="A great deal">A great deal</option><option value="A lot">A lot</option><option value="A little">A little</option><option value="None at all">None at all</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">During the past 12 months, has the child participated in any of the following after school or weekend activities? (check all that apply)</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Academic support or tutoring">Academic support or tutoring</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Sports or athletic activities">Sports or athletic activities</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Lessons in art, performing arts, music, or dance">Lessons in art, performing arts, music, or dance</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Clubs or organizations">Clubs or organizations</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Religious instruction or youth group">Religious instruction or youth group</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Volunteer activities">Volunteer activities</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="Part-time job or internship">Part-time job or internship</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_118" value="None of the above">None of the above</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_118" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_118_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 required">During the past 12 months, has the child? (check all that apply)</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Skipped school or cut classes without your permission">Skipped school or cut classes without your permission</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Received an in-school suspension">Received an in-school suspension</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Received an out-of-school suspension">Received an out-of-school suspension</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Been expelled">Been expelled</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Been in trouble with the law or juvenile justice system">Been in trouble with the law or juvenile justice system</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Been involved in a gang">Been involved in a gang</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="Run away for a period of more than 7 days">Run away for a period of more than 7 days</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_119" value="None of the above">None of the above</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_119" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_119_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 required">Recreational activities: (interests, community activities, client�s view of relationships with peers, self-care skills, motor activity level)</label><textarea name="CST_120" style="width:100%;" class="er_fld_required"></textarea></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">Is your child/ family involved in a church?</label><select name="CST_134" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></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">Please provide any details on your child's religious history/ views below.  (religious preference, denomination, importance to child, importance to family, etc)</label><textarea name="CST_135" style="width:100%;" class="er_fld_required"></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>Safety/ Behavior Concerns</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">Please tell us about your child's safety or behavior concerns (current or present within the last 6 months).</div></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">Are there imminent safety issues?</label><select name="CST_121" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></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 required">Dangers to self (check all that apply):</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="None">None</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Thoughts of Suicide">Thoughts of Suicide</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Threats of Suicide">Threats of Suicide</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Plan for Suicide">Plan for Suicide</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Suicidal Gesture">Suicidal Gesture</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Suicide Attempts">Suicide Attempts</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_122" value="Family History of Suicide">Family History of Suicide</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_122" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_122_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 required">Danger to others (check all that apply):</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="None">None</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Thoughts of Homicide">Thoughts of Homicide</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Threats of Homicide">Threats of Homicide</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Homicidal Plan">Homicidal Plan</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Homicidal Gestures">Homicidal Gestures</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Homicide Attempts">Homicide Attempts</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_123" value="Family History of Harming Others">Family History of Harming Others</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_123" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_123_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" er_fld_condvals="er_fld_showif_values=Plan+for+Suicide&amp;er_fld_showif_values=Suicidal+Gesture&amp;er_fld_showif_values=Suicide+Attempts&amp;er_fld_showif_values=Family+History+of+Suicide" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Please provide additional information on anything you checked above:</label><textarea name="CST_124" style="width:100%;"></textarea></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">Should a safety plan be developed / implemented? </label><select name="CST_125" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></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">Are there known stressors or triggers?</label><select name="CST_126" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_126" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Please explain (type, response, frequency of occurrence)</label><textarea name="CST_127" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Acute behavior(s) (check all that apply)</label>

<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="None">None</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Stealing">Stealing</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Fire Setting">Fire Setting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Runaway">Runaway</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Excessive Fighting">Excessive Fighting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Aggressive">Aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Destroys Property">Destroys Property</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Sexually Inappropriate Behavior">Sexually Inappropriate Behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Self-harming Behaviors">Self-harming Behaviors</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Risk-taking Behavior">Risk-taking Behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Inappropriate Social Media Interaction">Inappropriate Social Media Interaction</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Alcohol Use Illegal/Prescription Drug Use">Alcohol Use Illegal/Prescription Drug Use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Manipulation">Manipulation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Habitual Lying">Habitual Lying</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_128" value="Bedwetting">Bedwetting</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_128" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_128_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" er_fld_condvals="er_fld_showif_values=Stealing&amp;er_fld_showif_values=Fire+Setting&amp;er_fld_showif_values=Runaway&amp;er_fld_showif_values=Excessive+Fighting&amp;er_fld_showif_values=Aggressive&amp;er_fld_showif_values=Destroys+Property&amp;er_fld_showif_values=Sexually+Inappropriate+Behavior&amp;er_fld_showif_values=Self-harming+Behaviors&amp;er_fld_showif_values=Risk-taking+Behavior&amp;er_fld_showif_values=Inappropriate+Social+Media+Interaction&amp;er_fld_showif_values=Alcohol+Use+Illegal%2FPrescription+Drug+Use&amp;er_fld_showif_values=Manipulation&amp;er_fld_showif_values=Habitual+Lying&amp;er_fld_showif_values=Bedwetting" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Please explain (frequency and duration of behaviors)</label><textarea name="CST_129" style="width:100%;" class="er_fld_required"></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 required">Has the child been involved in the criminal justice system?</label><select name="CST_147" class="er_fld_required"><option value=""></option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_147" er_fld_condvals="er_fld_showif_values=Yes" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">If yes, please specify with details and time of involvement.</label><input name="CST_145" 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>Services</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">Please tell us about past and current resources and services you use/ have used in the past with your child.  </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 required">Current Resources and Services (include provider name, date(s) of services and a brief description)</label><textarea name="CST_130" 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">Past Resources and Services (include provider name, date(s) of services and a brief description)</label><textarea name="CST_131" style="width:100%;" class="er_fld_required"></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>Trauma/ Loss History</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">Please tell us about your child's trauma and loss history.  
This may include history of sexual or physical abuse, history of neglect, death of family member or significant friend, separations from caretaker, witness of domestic violence or other violence, survived a natural disaster, house fire, car accident, intrusive medical procedures, significant medical history/events.</div></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 required">Is your child currently placed in foster care?</label><select name="CST_138" class="er_fld_required"><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Number of removals/ placements outside the home</label><select name="CST_139" class="er_fld_required"><option value="0">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7 or more">7 or more</option></select></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">County of Removal</label><input name="CST_143" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label">Case Workers Name</label><input name="CST_140" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label">Caseworker Email</label><input name="CST_141" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label">Caseworker Phone</label><input name="CST_142" 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 required">Trauma History</label><textarea name="CST_132" 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">Loss History</label><textarea name="CST_133" style="width:100%;" class="er_fld_required"></textarea></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>Treatment History</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">Please provide detailed information on your child's treatment history.
This may include services received and response to services, community resources tried, family�s attitude toward treatment, what role has family played in treatment, what has worked best</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 required">Treatment History</label><textarea name="CST_136" style="width:100%;" class="er_fld_required"></textarea></li></ul>