Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Teen Parent Connection (TPC) Referral Form </label><hr></li></ul><ul class="er_fld_row"><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_required" name="CST_1" type="text" value=""></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">Name of Referring Agency</label><input name="CST_2" 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 required">Agency Type</label><input name="CST_3" 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%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of Person Making Referral</label><input name="CST_4" 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 required">Position</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 50%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_7" type="text" class="er_fld_required"></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">Signature of Legal Guardian/Referral Source</label><div class="cst_signaturepad"></div><input name="CST_8" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Teen First Name</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Teen Last Name</label><input name="CST_108" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB"> <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_10" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Gender Queer">Gender Queer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Gender Expansive">Gender Expansive</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Trans Female">Trans Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Trans Male">Trans Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Questioning/Exploring">Questioning/Exploring</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="I’m not sure">I’m not sure</label><label class="er_option"><input class="type_radio" type="radio" name="CST_30" value="Prefer not to respond">Prefer not to respond</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_30" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_30_Other" type="text"></label></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Age</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;" map_to="CC_SSN"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Social Security Number</label><input name="CST_12" type="text" class=""></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">Name of Parent / Guardian #1</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_15" 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%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Parent / Guardian #2</label><input name="CST_14" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Phone Number</label><input name="CST_16" type="text"></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">Address of Teen Residence</label><input name="CST_17" 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_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City of Teen Residence</label><input name="CST_109" type="text" class="er_fld_required"></li><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 of Teen Residence</label><input name="CST_110" type="text" value="GA" 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 of Teen Residence</label><input name="CST_111" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County of Teen Residence</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_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Teen’s Email</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: 33.3333%;" map_to="CC_Language"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Language</label><input name="CST_20" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Language_B"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Language</label><input name="CST_21" type="text" class="er_fld_blank"></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">DFCS Case Manager Name</label><input name="CST_22" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DFCS Case Manager County</label><input name="CST_23" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DCFS Case Manager Email</label><input name="CST_24" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">DFCS Case Manager Work Phone</label><input name="CST_25" type="text"></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" map_to="CC_Race"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Race</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Caucasian ">Caucasian </label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="African American">African American</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Latino">Latino</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Native American ">Native American </label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Asian/Pacific Islander ">Asian/Pacific Islander </label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Multi-Racial">Multi-Racial</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Unknown ">Unknown </label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_26" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_26_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Pregnancy Status</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_27" value="Suspected Pregnancy">Suspected Pregnancy</label><label class="er_option"><input class="type_radio" type="radio" name="CST_27" value="Pregnant (confirmed) ">Pregnant (confirmed) </label><label class="er_option"><input class="type_radio" type="radio" name="CST_27" value="Parenting">Parenting</label><label class="er_option"><input class="type_radio" type="radio" name="CST_27" value="Pregnant & Parenting ">Pregnant & Parenting </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_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Parenting+(See+Next)%09+++++++&er_fld_showif_values=Pregnant+%26+Parenting+(See+Next)%09+++++++"> <i class="fa fa-hashtag"></i><label class="er_fld_label"># of Living Children</label><input name="CST_28" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">What is the legal status of the teen parent? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_31" value="DFCS Custody ">DFCS Custody </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_31" value="DJJ Custody">DJJ Custody</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">What is teen parent’s marital status? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Single ">Single </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Married ">Married </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Divorced ">Divorced </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Separated ">Separated </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Live-In Partner">Live-In Partner</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_32" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_32_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">If not married, is teen parent in a dating relationship?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_33" value="Yes">Yes</label><label class="er_option"><input class="type_radio" type="radio" name="CST_33" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_33" value="Unknown">Unknown</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_33" value="Other:">Other:<input class="cst_Other" name="CST_33_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Information on Living Children of Teen Parent</div></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_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-font"></i><label class="er_fld_label required">Name (Child #1)</label><input name="CST_34" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-font"></i><label class="er_fld_label required">Date of Birth</label><input name="CST_35" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Female ">Female </label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Gender Queer">Gender Queer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Gender Expansive">Gender Expansive</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Trans Female">Trans Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Trans Male">Trans Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Questioning/Exploring">Questioning/Exploring</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="I’m not sure">I’m not sure</label><label class="er_option"><input class="type_radio" type="radio" name="CST_38" value="Prefer not to respond">Prefer not to respond</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_38" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_38_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Residence</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" value="Teen Parent ">Teen Parent </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" value="Maternal Relative ">Maternal Relative </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" value="Paternal Relative ">Paternal Relative </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" value="Foster Home">Foster Home</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_39" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_39_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Race</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Caucasian ">Caucasian </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="African American">African American</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Latino">Latino</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Native American ">Native American </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Asian/Pacific Islander ">Asian/Pacific Islander </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_37" value="Multi-Racial ">Multi-Racial </label><label class="er_option er_option_other"><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><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Legal Status</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="State Custody ">State Custody </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="Parent ">Parent </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="Other Guardianship ">Other Guardianship </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="Unknown">Unknown</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_40" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_40_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-header"></i><label></label><hr></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_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-font"></i><label class="er_fld_label">Name (Child #2)</label><input name="CST_41" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth</label><input class="cst_datepicker er_fld_blank" name="CST_42" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Female ">Female </label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Gender Queer">Gender Queer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Gender Expansive">Gender Expansive</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Trans Female">Trans Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Trans Male">Trans Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Questioning/Exploring">Questioning/Exploring</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="I’m not sure">I’m not sure</label><label class="er_option"><input class="type_radio" type="radio" name="CST_43" value="Prefer not to respond">Prefer not to respond</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_43" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_43_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Residence</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_44" value="Teen Parent ">Teen Parent </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_44" value="Maternal Relative ">Maternal Relative </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_44" value="Paternal Relative ">Paternal Relative </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_44" value="Foster Home">Foster Home</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_44" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_44_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Race</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="Caucasian ">Caucasian </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="African American">African American</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="Latino">Latino</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="Native American ">Native American </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="Asian/Pacific Islander ">Asian/Pacific Islander </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_46" value="Multi-Racial ">Multi-Racial </label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_46_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Legal Status</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_45" value="State Custody ">State Custody </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_45" value="Parent ">Parent </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_45" value="Other Guardianship ">Other Guardianship </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_45" value="Unknown">Unknown</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_45" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_45_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-header"></i><label></label><hr></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_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-font"></i><label class="er_fld_label">Name (Child #3)</label><input name="CST_47" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth</label><input class="cst_datepicker er_fld_blank" name="CST_48" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif er_fld_selected" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Female">Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Agender">Agender</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Gender Queer">Gender Queer</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Gender Expansive">Gender Expansive</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Trans Female">Trans Female</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Trans Male">Trans Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Questioning/Exploring">Questioning/Exploring</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="I’m not sure">I’m not sure</label><label class="er_option"><input class="type_radio" type="radio" name="CST_49" value="Prefer not to respond">Prefer not to respond</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_49" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_49_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Residence</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_50" value="Teen Parent ">Teen Parent </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_50" value="Maternal Relative ">Maternal Relative </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_50" value="Paternal Relative ">Paternal Relative </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_50" value="Foster Home">Foster Home</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_50" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_50_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Race</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Caucasian ">Caucasian </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="African American">African American</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Latino">Latino</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Native American ">Native American </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Asian/Pacific Islander ">Asian/Pacific Islander </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_52" value="Multi-Racial ">Multi-Racial </label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_52" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_52_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label">Legal Status</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_51" value="State Custody ">State Custody </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_51" value="Parent ">Parent </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_51" value="Other Guardianship ">Other Guardianship </label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_51" value="Unknown">Unknown</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank" type="radio" name="CST_51" value="Other:">Other:<input class="cst_Other er_fld_blank" name="CST_51_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does teen retain parental rights for children?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_53" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_53" 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_53" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_53_Other" type="text"></label> </li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-calendar"></i><label class="er_fld_label">If no, date parental rights terminated:</label><input class="cst_datepicker er_fld_blank" name="CST_54" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is teen interested in regaining custody and/or keeping parental rights?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_55" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_55" 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_55" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_55_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_27" er_fld_condvals="er_fld_showif_values=Pregnant+(confirmed)%09++++++++&er_fld_showif_values=Parenting&er_fld_showif_values=Pregnant+%26+Parenting++"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If parenting, has teen been investigated due to child abuse or neglect report?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_56" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_56" 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_56" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_56_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If yes, was report substantiated? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_57" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_57" 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_57" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_57_Other" type="text"></label> </li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-calendar"></i><label class="er_fld_label required">If yes, date of substantiation</label><input class="cst_datepicker er_fld_blank er_fld_required" name="CST_58" type="text"></li><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is case currently open?</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_59" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_blank er_fld_required" type="radio" name="CST_59" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_blank er_fld_required" type="radio" name="CST_59" value="Other:">Other:<input class="cst_Other er_fld_blank er_fld_required" name="CST_59_Other" type="text"></label> </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">Current residence at time of referral?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Parent(s)/Guardian(s)">Parent(s)/Guardian(s)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Relative over 20 yrs. ">Relative over 20 yrs. </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Relative under 20 yrs.">Relative under 20 yrs.</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Friend(s) ">Friend(s) </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Family of Child(ren)’s Father ">Family of Child(ren)’s Father </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Foster home">Foster home</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Father of Child(ren)">Father of Child(ren)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Boyfriend/Partner">Boyfriend/Partner</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Apartment (Public) ">Apartment (Public) </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Apartment (Fair Market) ">Apartment (Fair Market) </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Shelter/Homeless">Shelter/Homeless</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="Group Home">Group Home</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="GCAPP SCH: Indicate home below">GCAPP SCH: Indicate home below</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="GCAPP ITLS/TLP: Indicate site below">GCAPP ITLS/TLP: Indicate site below</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_60" value="DFCS TLP: Indicate site below">DFCS TLP: Indicate site below</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_60" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_60_Other" type="text"></label></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_60" er_fld_condvals="er_fld_showif_values=GCAPP+SCH%3A+Indicate+home+below&er_fld_showif_values=GCAPP+ITLS%2FTLP%3A+Indicate+site+below&er_fld_showif_values=DFCS+TLP%3A+Indicate+site+below"> <i class="fa fa-font"></i><label class="er_fld_label required">Indicate GCAPP SCH / GCAPP ITLS-TLP / DFCS TLP Name </label><input name="CST_61" type="text" class="er_fld_required"></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">Why was teen referred to TPC services?</label><input name="CST_62" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has teen been involved in any criminal activity? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="Unknown (Not Current)">Unknown (Not Current)</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_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If yes, was teen arrested?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="Unknown">Unknown</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_64" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_64_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3 er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Was teen adjudicated?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_65" value="Unknown">Unknown</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_65" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_65_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is teen currently under probation?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="Unknown">Unknown</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_66" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_66_Other" type="text"></label></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: 100%;" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes to any of the above, please describe</label><textarea name="CST_67" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space:normal;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required"> Does teen have a history of substance abuse?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="Unknown">Unknown</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_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does teen have a history of mental health concerns/treatment? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="Unknown">Unknown</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_69" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_69_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is teen currently smoking tobacco (as a habit)?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_70" value="Unknown">Unknown</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_70" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_70_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is teen currently taking any prescription medications?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_71" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_71" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_71" value="Unknown">Unknown</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_71" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_71_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has teen ever run away from home or any placement?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_72" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_72" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_72" value="Unknown">Unknown</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_72" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_72_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">If yes to any of the above, please describe</label><textarea name="CST_73" style="width:100%;" class="er_fld_blank"></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>Educational Information</label><hr></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">School Status:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Obtained High School Diploma ">Obtained High School Diploma </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Obtained High School Certificate of Attendance">Obtained High School Certificate of Attendance</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Obtained GED ">Obtained GED </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending Jr. High or High School">Attending Jr. High or High School</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Not Enrolled in School">Not Enrolled in School</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending GED Program ">Attending GED Program </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending Technical/Vocational School">Attending Technical/Vocational School</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending 2 Year College">Attending 2 Year College</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending 4 Year College">Attending 4 Year College</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Attending Alternative School">Attending Alternative School</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_74" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_74_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If not enrolled in school, please indicate last grade completed</label><input name="CST_76" type="text" class="er_fld_width100"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If currently enrolled, provide name of School/Program and grade level</label><input name="CST_75" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does teen have an educational goal? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_77" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_77" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_77" value="Unknown">Unknown</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_77" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_77_Other" type="text"></label></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_77" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please describe</label><textarea name="CST_78" style="width:100%;"></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>Employment Information</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_bold">Previous Employment Status</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Employed Full-Time</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_81" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_81" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_81" value="Unknown">Unknown</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_81" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_81_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Employed Part-Time</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_80" value="Unknown">Unknown</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_80" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_80_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Internship/Job Training</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_82" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_82" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_82" value="Unknown">Unknown</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_82" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_82_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Odd Jobs/Irregular PT</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_83" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_83" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_83" value="Unknown">Unknown</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_83" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_83_Other" type="text"></label></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_bold">Current Employment Status</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Employed Full-Time</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_85" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_85" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_85" value="Unknown">Unknown</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_85" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_85_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Employed Part-Time</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_84" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_84" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_84" value="Unknown">Unknown</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_84" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_84_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Internship/Job Training</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_86" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_86" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_86" value="Unknown">Unknown</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_86" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_86_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Odd Jobs/Irregular PT</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_87" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_87" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_87" value="Unknown">Unknown</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_87" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_87_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If unemployed, is teen looking for work? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_88" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_88" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_88" value="Unknown">Unknown</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_88" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_88_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does teen have a bank account? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_89" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_89" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_89" value="Unknown">Unknown</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_89" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_89_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Driving Status</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" value="Current Driver's Permit">Current Driver's Permit</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" value="Current Driver's License">Current Driver's License</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_90" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_90_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has teen had any driving violations?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_91" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_91" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_91" value="Unknown">Unknown</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_91" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_91_Other" type="text"></label></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_91" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes to driving violations, describe briefly</label><textarea name="CST_112" style="width:100%;" class="er_fld_required"></textarea></li></ul>
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