Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<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: 25%;"> <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" data-fillr-id="1124238729"></li><li class="er_fld_type_text" draggable="false" map_to="CC_MiddleInitial" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Middle Name</label><input name="CST_2" type="text" class="er_fld_required er_fld_width50" data-fillr-id="174448818"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" 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" data-fillr-id="424625615"></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</label><input name="CST_15" type="text" class="er_fld_required er_fld_width100" data-fillr-id="1263274164"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;" map_to="CC_PersonalPhone"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_16" type="text" class="er_fld_required er_fld_width50" data-fillr-id="1646217405"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" 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_width50" data-fillr-id="609995138"></li></ul><ul class="er_fld_row"><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 er_fld_width50" name="CST_4" type="text" data-fillr-id="609352909"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <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_width50" data-fillr-id="1484447494"></li><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Gender" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_35" class="er_fld_required er_fld_width50" data-fillr-id="1745536789"><option value=""></option><option value="Male">Male</option><option value="Female">Female</option></select></li></ul><ul class="er_fld_row"><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_width50" data-fillr-id="1370355800"><option value=""></option><option value="American Indian or Alaska Native">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><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Ethnicity</label><select name="CST_11" class="er_fld_width50" data-fillr-id="199935265"><option value="Other Nationality">Other Nationality</option><option value="Hispanic or Latino" selected="">Hispanic or Latino</option><option value="Haitian">Haitian</option><option value="Jamaican">Jamaican</option><option value=" " selected=""> </option></select></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_width50" data-fillr-id="1509090898"><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%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Dropdown</label><select name="CST_187" class="er_fld_required er_fld_width50"><option value="Community">Community</option><option value="EFC">EFC</option><option value="PESS">PESS</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Birthplace"> <i class="fa fa-font"></i><label class="er_fld_label required">Place of Birth</label><input name="CST_12" type="text" class="er_fld_width50 er_fld_required" data-fillr-id="1212893938"></li><li class="er_fld_type_number" draggable="false" map_to="CC_SSN" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Social Security #</label><input name="CST_13" type="text" class="er_fld_required er_fld_width50" data-fillr-id="505897969"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">State ID/DL#</label><input name="CST_186" type="text" data-fillr-id="371599684" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" 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_width50" data-fillr-id="1857175526"></li><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Language{s}</label><input name="CST_19" type="text" class="er_fld_width50" data-fillr-id="415408839"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Church Home</label><input name="CST_21" type="text" class="er_fld_width50" data-fillr-id="1951258860"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" 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_width50" data-fillr-id="368245888"></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">Primary Doctor</label><input name="CST_23" type="text" class="er_fld_width50" data-fillr-id="238408056"></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_width50" data-fillr-id="1803422449"></li><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_width50" data-fillr-id="1026887959"></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_width50" data-fillr-id="1535619158"></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_width50" data-fillr-id="249139371"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">License Plate</label><input name="CST_27" type="text" class="er_fld_width50" data-fillr-id="1662037592"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Reason for Applying to TIL 2:25</label><input name="CST_28" type="text" class="er_fld_required" data-fillr-id="1771062038"></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">REFERRAL SOURCE AND CONTACTS</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Name</label><input name="CST_29" type="text" class="er_fld_required er_fld_width50" data-fillr-id="379916383"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label">Agency Name</label><input name="CST_32" type="text" class="er_fld_width50" data-fillr-id="2116533241"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <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_width50 er_fld_required" data-fillr-id="1405090975"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 25%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_30" type="text" class="er_fld_width50 er_fld_required" data-fillr-id="1683249350"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_31" type="text" class="er_fld_width50 er_fld_required" data-fillr-id="462245977"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Fax Number</label><input name="CST_36" type="text" class="er_fld_width50" data-fillr-id="144233104"></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">Life Coach: Name</label><input name="CST_37" type="text" class="er_fld_width50" data-fillr-id="1278918571"></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_39" type="text" class="er_fld_width50" data-fillr-id="1858908711"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_40" type="text" class="er_fld_width50" data-fillr-id="1869656245"></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">IL Specialist: Name</label><input name="CST_41" type="text" class="er_fld_width50" data-fillr-id="506424172"></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_42" type="text" class="er_fld_width50" data-fillr-id="538641797"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_45" type="text" class="er_fld_width50" data-fillr-id="800193380"></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">Therapist: Name</label><input name="CST_46" type="text" class="er_fld_width50" data-fillr-id="1778877262"></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_48" type="text" class="er_fld_width50" data-fillr-id="2008063678"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_49" type="text" class="er_fld_width50" data-fillr-id="1274989853"></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">Emergency Contact</label><input name="CST_50" type="text" class="er_fld_width50 er_fld_required" data-fillr-id="1981679817"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_52" type="text" class="er_fld_width50 er_fld_required" data-fillr-id="747159183"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <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_width50 er_fld_required" data-fillr-id="1449732460"></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">ADDITIONAL INFORMATION</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">Has the applicant ever been involved with human trafficking?</label><select name="CST_189" class="er_fld_required"><option value=""></option><option value="No" selected="">No</option><option value="Yes">Yes</option><option value=""></option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_189" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, when was the last involvement</label><input name="CST_188" type="text" class=""></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 been arrested or had any prior involvement with law enforcement?</label><select name="CST_190" class="er_fld_width50 er_fld_required"><option value=""></option><option value="No" selected="">No</option><option value="Yes">Yes</option></select></li><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 applicant or has applicant ever been on probation?</label><select name="CST_53" class="er_fld_required er_fld_width50" data-fillr-id="87433471"><option value=""></option><option value="Yes">Yes</option><option value="No" selected="">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Probation Officer</label><input name="CST_54" type="text" class="er_fld_width50" data-fillr-id="1482140592"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Phone Number</label><input name="CST_55" type="text" class="er_fld_width50" data-fillr-id="1895670435"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">How long is the probation period?</label><input name="CST_56" type="text" class="er_fld_width50" data-fillr-id="1390153629"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-caret-down"></i><label class="er_fld_label">Is the applicant required to complete community service hours?</label><select name="CST_57" class="er_fld_width50" data-fillr-id="1046494193"><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_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">How many hours, and are there additional conditions?</label><textarea name="CST_58" style="width:100%;" class="er_fld_width50" data-fillr-id="850610474"></textarea></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Do you have any court obligations (i.e. fines, community service, letters)? If so, please explain.</label><textarea name="CST_59" style="width:100%;" class="er_fld_width50" data-fillr-id="1484832631"></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></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: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does applicant use drugs?</label><select name="CST_60" class="er_fld_required er_fld_width100" data-fillr-id="878806269"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif sortable-chosen" draggable="true" style="width: 25%;" er_fld_condfld="CST_60" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">What types of drugs does the applicant use?</label><input name="CST_61" type="text" class="er_fld_width100" data-fillr-id="726141360"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_60" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Frequency and date of last use.</label><input name="CST_62" type="text" data-fillr-id="340775659"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_60" er_fld_condvals="er_fld_showif_values=Yes"><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" data-fillr-id="952423769"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_60" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name of substance, date of overdose, and treatment given, required.</label><input name="CST_66" type="text" data-fillr-id="598968154"></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 INFORMANCE</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label">School Currently Attending</label><input name="CST_69" type="text" class="er_fld_width50" data-fillr-id="1390809499"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;" map_to="CC_School_Phone"> <i class="fa fa-hashtag"></i><label class="er_fld_label">School Phone Number</label><input name="CST_71" type="text" class="er_fld_width50" data-fillr-id="1934984686"></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">Expected Graduation Date</label><input name="CST_73" type="text" class="er_fld_width50" data-fillr-id="1879311027"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_School_Grade"> <i class="fa fa-font"></i><label class="er_fld_label">Current Grade Level</label><input name="CST_72" type="text" class="er_fld_width50" data-fillr-id="1014142762"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_School_Comments" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Education Goals</label><input name="CST_74" type="text" data-fillr-id="1843872399"></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">EMPLOYMENT HISTORY</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> </div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Current Employment</div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Previous Employment</div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Prior Employment</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Employed by (company)</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Employ_Employer"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_129" type="text" data-fillr-id="777902857"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_130" type="text" data-fillr-id="175696943"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_131" type="text" data-fillr-id="389687640"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Address</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_133" type="text" data-fillr-id="99410840"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_134" type="text" data-fillr-id="1813138513"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_135" type="text" data-fillr-id="1269273198"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Employer's phone</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_139" type="text" data-fillr-id="898764636"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_137" type="text" data-fillr-id="298333976"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_128" type="text" data-fillr-id="1575395200"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Occupation</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_142" type="text" data-fillr-id="751257978"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_141" type="text" data-fillr-id="1379994363"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_143" type="text" data-fillr-id="799650056"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Name of supervisor</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_146" type="text" data-fillr-id="1840905931"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_147" type="text" data-fillr-id="1446563976"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_145" type="text" data-fillr-id="872663372"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Monthly Gross Pay</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_149" type="text" data-fillr-id="279094926"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_150" type="text" data-fillr-id="1151992410"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_151" type="text" data-fillr-id="803645283"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> </div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">From/To</div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">From/To</div></li><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">From/To</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 20%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Dates of employment</div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Employ_Since"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_158" type="text" data-fillr-id="996695226"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_157" type="text" data-fillr-id="2135811321"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_159" type="text" data-fillr-id="60741391"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Employ_Comments" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Employment Goals</label><input name="CST_160" type="text" data-fillr-id="1621405749"></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">MENTAL HEALTH</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">Has the applicant ever seen a psychiatrist or mental health therapist?</label><select name="CST_161" class="er_fld_required er_fld_width50" data-fillr-id="840740964"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_161"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If yes, please complete the following with the most recent information.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_161" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Psychiatrist/Psychologist Name</label><input name="CST_162" type="text" class="er_fld_width50" data-fillr-id="816132683"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_161"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Phone Number</label><input name="CST_163" type="text" class="er_fld_width50" data-fillr-id="1234494154"></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">Current Medications: (include dosages)</label><textarea name="CST_165" style="width:100%;" data-fillr-id="1591804314"></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 applicant ever been hospitalized and/or admitted to a residential treatment facility?</label><select name="CST_166" class="er_fld_width50 er_fld_required" data-fillr-id="1312008100"><option value=""></option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <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_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_width100" name="CST_171" type="text" data-fillr-id="1133119005"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Hospital</label><input class="cst_datepicker" name="CST_167" type="text" data-fillr-id="187167384"></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_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Reason for hospitalization</label><input name="CST_168" type="text" data-fillr-id="283634237"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Number of days in the hospital</label><input name="CST_170" type="text" data-fillr-id="898387933"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Outcome</label><input name="CST_173" type="text" data-fillr-id="1356916011"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker" name="CST_174" type="text" data-fillr-id="1960825734"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Hospital</label><input name="CST_175" type="text" data-fillr-id="1872918478"></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_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Reason for hospitalization</label><input name="CST_176" type="text" data-fillr-id="1181142700"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Number of days in the hospital</label><input name="CST_177" type="text" data-fillr-id="1151161813"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_166" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Outcme</label><input name="CST_178" type="text" data-fillr-id="775768230"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please check all current presenting problems or choose Other and enter NONE </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Abandonment">Abandonment</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Neglect">Neglect</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Physical Abuse">Physical Abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Sexual Abuse">Sexual Abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Physically aggressive">Physically aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Verbally aggressive">Verbally aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Alcohol use">Alcohol use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Drug use">Drug use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Tobacco use">Tobacco use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Anger management">Anger management</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Argumentative">Argumentative</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Bed wetting">Bed wetting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Clothes soiling">Clothes soiling</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Clothes wetting">Clothes wetting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Cruelty to animals">Cruelty to animals</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Curfew problems">Curfew problems</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Defiant">Defiant</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Delinquency">Delinquency</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Destructive">Destructive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Disrespectful to authority figures">Disrespectful to authority figures</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Extreme sibling rivalry">Extreme sibling rivalry</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Easily agitated">Easily agitated</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Fighting">Fighting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Fire setting">Fire setting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Gang related behavior">Gang related behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Hostile">Hostile</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Hyperactive">Hyperactive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Hypoactive">Hypoactive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Lacks responsibility">Lacks responsibility</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Lacks respect for others">Lacks respect for others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Lying">Lying</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Manipulative">Manipulative</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Mood swings">Mood swings</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Sadness">Sadness</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Excessive crying">Excessive crying</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Negative attitude">Negative attitude</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Inappropriate peer relations">Inappropriate peer relations</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="No or low motivation">No or low motivation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="No remorse for actions">No remorse for actions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Poor hygiene">Poor hygiene</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Poor self-image">Poor self-image</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="History of running away">History of running away</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Self injurious behavior">Self injurious behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Sexually inappropriate behavior">Sexually inappropriate behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Sexual perpetrator">Sexual perpetrator</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Socially isolated">Socially isolated</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Stealing">Stealing</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Truancy">Truancy</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Violent behavior">Violent behavior</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Suicidal ideations/gestures">Suicidal ideations/gestures</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Suicidal attempts">Suicidal attempts</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Homicidal ideations/gestures">Homicidal ideations/gestures</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Homicidal attempts">Homicidal attempts</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Worries excessively">Worries excessively</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_179" value="Withdrawal">Withdrawal</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_179" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_179_Other" type="text" data-fillr-id="1792797670"></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">REQUIRED ESSAY</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Please complete an essay describing yourself, your history, your hopes, and goals for the future. Also include why you are seeking admission into the transitional living program.</label><textarea name="CST_180" style="width:100%;" class="er_fld_required" data-fillr-id="83426655"></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></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">APPLICANT AGREEMENT AND SIGNATURE</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">I believe that the statements I have made are true and correct. I hereby authorize a credit and/or criminal check to be made, verification of information I provided and communication with any and all names listed on this application. I understand that any discrepancy or lack of information may result in the rejection of this application. I understand that this is an application for an apartment and does not constitute a rental or lease agreement in whole or in part.</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" data-fillr-id="64246029"></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" data-fillr-id="363980799"></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" data-fillr-id="1804652707"><button class="type_button" disabled="">Clear Signature</button></li></ul>
Submit