Online Referral
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<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">GENERAL INFORMATION</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_FirstName" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_3" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 20%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required er_fld_width100" name="CST_4" 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 required">Age</label><input name="CST_6" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">US Citizen</label><select name="CST_10" class="er_fld_required er_fld_width100"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_7" class="er_fld_required er_fld_width100"><option value=""></option><option value="American Indian or Alaska Native" selected="">American Indian or Alaska Native</option><option value="Asian">Asian</option><option value="Black or African American">Black or African American</option><option value="Native Hawaiian or Pacific Islander">Native Hawaiian or Pacific Islander</option><option value="White">White</option><option value="Multiracial">Multiracial</option><option value="Unknown">Unknown</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="none"> <i class="fa fa-font"></i><label class="er_fld_label required">Do you have children? If yes, list their names and ages</label><input name="CST_12" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" map_to="none" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Do all of your children live with you?</label><input name="CST_2" type="text" class="er_fld_width100 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Address/Living Situation</label><input name="CST_15" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City/State</label><input name="CST_189" type="text" class="er_fld_width100 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">Zip</label><input name="CST_186" type="text" class="er_fld_width100 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_PersonalPhone"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone number</label><input name="CST_219" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_PersonalEmail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_17" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_PrimaryLanguage"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Language</label><input name="CST_18" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Language{s}</label><input name="CST_19" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Religion"> <i class="fa fa-font"></i><label class="er_fld_label">Religion</label><input name="CST_20" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Church Home</label><input name="CST_21" type="text" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label required">Social Security Number</label><input name="CST_220" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">State ID/DL #</label><input name="CST_221" 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">Automobile Make</label><input name="CST_25" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Model</label><input name="CST_26" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">License Plate</label><input name="CST_222" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Reason for coming to His Caring Place</label><textarea name="CST_213" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">REFERRAL SOURCE AND CONTACTS</div></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">How did you hear about us?</label><input name="CST_188" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Name</label><input name="CST_29" type="text" class="er_fld_required er_fld_width100"></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">Title/Relationship to Applicant</label><input name="CST_33" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_223" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_31" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Emergency Contact</label><input name="CST_50" type="text" class="er_fld_required er_fld_width100"></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">Relationship to Applicant</label><input name="CST_51" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_214" 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">City/State</label><input name="CST_215" 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">Zip</label><input name="CST_216" type="text"></li><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_225" 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></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">PREGNANCY AND MEDICAL INFORMATION</div></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 required">Do you have medical insurance? If yes, which insurance?</label><input name="CST_199" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Medicaid Number</label><input name="CST_22" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Primary Doctor</label><input name="CST_23" type="text" class="er_fld_width100"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Phone Number</label><input name="CST_24" type="text" class="er_fld_width100"></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">How far along are you?</label><input name="CST_190" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Is this your first pregnancy?</label><select name="CST_192"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</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">Have you received pre-natal care?</label><select name="CST_193"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</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">OBGYN Name and Location</label><input name="CST_194" 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">When was your last OBGYN Appointment?</label><input name="CST_196" 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">Have you experienced any difficulties with your pregnancy? If yes, please explain.</label><input name="CST_197" 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>BIRTH PLAN</label><hr></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">Do you plan to parent or create an adoption plan?</label><select name="CST_201"><option value="Parent">Parent</option><option value="Create Adoption Plan">Create Adoption Plan</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">If accepted, do you plan to give birth at HCP?</label><input name="CST_202" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe the current relationship with the father of your child.</label><textarea name="CST_203" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">LEGAL</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">Have you ever been arrested? If yes, please explain.</label><textarea name="CST_218" style="width:100%;" class="er_fld_required"></textarea></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Do you have a probation officer? If yes, please provide contact information.</label><input name="CST_54" 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></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">SUBSTANCE ABUSE</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have a history of using drugs?</label><select name="CST_60" class="er_fld_required er_fld_width100"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, what types of drugs have been used?</label><input name="CST_61" type="text" class="er_fld_width100"></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">Frequency</label><input name="CST_62" 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">Date of last use</label><input name="CST_206" 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">Do you drink alcohol?</label><select name="CST_64" class="er_fld_required er_fld_width100"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, how often?</label><input name="CST_65" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Has applicant ever been hospitalized due to drugs and/or excessive drunkenness?</label><select name="CST_68"><option value=""></option><option value="Yes">Yes</option><option value="No">No</option></select></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">EDUCATION AND EMPLOYMENT</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label">Highest level of education received</label><input name="CST_69" type="text" class="er_fld_width100"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Do you have a job?</label><select name="CST_211"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</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">If yes, please provide details</label><input name="CST_209" 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">MENTAL HEALTH</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">Has the applicant ever seen a mental health professional, or been admitted to a hospital or residential treatment facility?</label><select name="CST_161" class="er_fld_required er_fld_width50"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><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">Current Medications: (include dosages)</label><textarea name="CST_165" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If yes, please complete the following</div></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">APPLICANT AGREEMENT AND SIGNATURE</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">Applicant Name</label><input name="CST_181" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date</label><input class="cst_datepicker er_fld_width50 er_fld_required" name="CST_182" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Applicant Signature</label><div class="cst_signaturepad"></div><input name="CST_183" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul>
Submit