Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 25%;"><i class="fa fa-header"></i><label>Cumberland Youth & Family Services Counseling Services</label><hr></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">COUNSELING REFERRAL SUBMISSION FORM Please use the form below to submit information about the person that will be participating in counseling services. If you are asking for couples or family counseling, you only need to submit one form and a counseling staff member will gather more information upon contact. </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">Client 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_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name:</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" 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_4" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's Email Address:</label><input name="CST_15" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's Phone Number:</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Insurance Status:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Unfunded (no insurance)">Unfunded (no insurance)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Private Insurance">Private Insurance</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Medicaid">Medicaid</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Medicare">Medicare</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_37" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_37_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="Nothing" er_fld_condfld="CST_37" er_fld_condvals="er_fld_showif_values=Private+Insurance&er_fld_showif_values=Medicaid&er_fld_showif_values=Medicare"> <i class="fa fa-font"></i><label class="er_fld_label required">Insurance Company:</label><input name="CST_39" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="Nothing" er_fld_condfld="CST_37" er_fld_condvals="er_fld_showif_values=Private+Insurance&er_fld_showif_values=Medicaid&er_fld_showif_values=Medicare"> <i class="fa fa-font"></i><label class="er_fld_label required">Insurance Member ID:</label><input name="CST_9" 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%;" map_to="CC_Education"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Education Level:</label><select name="CST_35" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</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="High School Graduate">High School Graduate</option><option value="GED">GED</option><option value="Some College">Some College</option><option value="Vocational/Trade School">Vocational/Trade School</option><option value="Associate's Degree">Associate's Degree</option><option value="Bachelor's Degree">Bachelor's Degree</option><option value="Master's Degree">Master's Degree</option><option value="Doctoral Degree">Doctoral Degree</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Employment"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Current Employment:</label><select name="CST_34" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Full Time Employment">Full Time Employment</option><option value="Part Time Employment">Part Time Employment</option><option value="Temporary Employment">Temporary Employment</option><option value="Contract/Independent Contractor">Contract/Independent Contractor</option><option value="Self-Employed">Self-Employed</option><option value="Unemployed">Unemployed</option><option value="Student">Student</option><option value="On Disability">On Disability</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Income"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Household Income Range:</label><select name="CST_27" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="A: Below - $5000">A: Below - $5000</option><option value="B: $5000 - $9999">B: $5000 - $9999</option><option value="C: $10000 - 14999">C: $10000 - 14999</option><option value="D: $15000 - $24999">D: $15000 - $24999</option><option value="E: $25000 - 34999">E: $25000 - 34999</option><option value="F: $35000 - 49999">F: $35000 - 49999</option><option value="G: $50000 - 74999">G: $50000 - 74999</option><option value="H: $75000 - $99999">H: $75000 - $99999</option><option value="I: $100000 - ABOVE">I: $100000 - ABOVE</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_FamSize"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Family Size:</label><select name="CST_33" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</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">7</option><option value="8">8</option><option value="9">9</option><option value="10 or more">10 or more</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_37" er_fld_condvals="er_fld_showif_values=Unfunded+(no+insurance)"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Income:</label><input name="CST_49" type="text" class="er_fld_required"></li></ul><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">Depending on funding source you may be asked to for documentation to show household income. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Gender"> <i class="fa fa-font"></i><label class="er_fld_label required">Gender:</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Race"> <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="- Not Specified -" selected="">- Not Specified -</option><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%;" map_to="Nothing"> <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="- Not Specified -" selected="">- Not Specified -</option><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></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's Address:</label><input name="CST_18" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City:</label><input name="CST_19" 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_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State:</label><input name="CST_20" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_21" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County:</label><input name="CST_40" type="text" class="er_fld_required"></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 required">What is your communication preference?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_47" value="Phone">Phone</label><label class="er_option"><input class="type_radio" type="radio" name="CST_47" value="Email">Email</label><label class="er_option"><input class="type_radio" type="radio" name="CST_47" value="Text">Text</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_47" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_47_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 required">Do you consent to receiving text messages? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="No">No</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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_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 required">Do you consent to receiving emails? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_46" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_46" value="No">No</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_46" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_46_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></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">If the client participating in counseling is a minor, please add legal guardian's information below:</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">Guardian's Name:</label><input name="CST_41" type="text"></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">Guardian's Relationship to Client:</label><select name="CST_44"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Mother (Biological)">Mother (Biological)</option><option value="Mother (Adoptive)">Mother (Adoptive)</option><option value="Mother (Foster)">Mother (Foster)</option><option value="Father (Biological)">Father (Biological)</option><option value="Father (Adoptive)">Father (Adoptive)</option><option value="Father (Foster)">Father (Foster)</option><option value="Relative: Aunt/Uncle">Relative: Aunt/Uncle</option><option value="Relative: Grandparent">Relative: Grandparent</option><option value="Relative: Sibling">Relative: Sibling</option><option value="Relative: Other">Relative: Other</option><option value="OCOK Permanency Specialist">OCOK Permanency Specialist</option></select></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">Guardian's Phone:</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">Guardian's Email Address:</label><input name="CST_43" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label">If you are not the client/guardian and are assisting with completing the referral form, please list your name:</label><input name="CST_48" 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></label><hr></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">How did you hear about us?</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Therapy Preference:</label><select name="CST_29" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Individual Therapy">Individual Therapy</option><option value="Family Therapy">Family Therapy</option><option value="Couples Therapy">Couples Therapy</option><option value="Play Therapy">Play Therapy</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" map_to="CC_Comments" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reason Seeking Counseling:</label><textarea name="CST_8" style="width:100%;" class="er_fld_required"></textarea></li></ul>
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