Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Community Based Services Request</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please enter your information into our secure form below:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please select the services you are seeking below (check any that apply):</label> <label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Community Stabilization (Crisis Stabilization)">Community Stabilization (Crisis Stabilization)</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Intensive In-Home">Intensive In-Home</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Supervised Visitation">Supervised Visitation</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Parent Coaching">Parent Coaching</label><label class="er_option"><input class="type_checkbox er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Mental Health Skill Building">Mental Health Skill Building</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required er_fld_desc" type="checkbox" name="CST_47" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_47_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">I am completing this form for:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="Myself">Myself</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="My Child">My Child</label><label class="er_option"><input class="type_radio" type="radio" name="CST_12" value="My Client">My Client</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_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Child&er_fld_showif_values=My+Client"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you have legal guardianship of this individual?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_49" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_49" 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_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=Myself" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">For Self-Referrals: Please note that this option only applies to Parent Coaching, Mental Health Skill Building, and Supervised Visitation. All other services require a referral.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Preferred Office Location:</label><select name="CST_13" class="er_fld_required"><option value="Lynchburg - Brook Park Place - Forest">Lynchburg - Brook Park Place - Forest</option><option value="Lynchburg - Connecting Point, Rivermont Ave">Lynchburg - Connecting Point, Rivermont Ave</option><option value="Harrisonburg">Harrisonburg</option><option value="Virginia Beach">Virginia Beach</option><option value="Fairfax">Fairfax</option><option value="Roanoke">Roanoke</option><option value="Bedford">Bedford</option><option value="Telehealth">Telehealth</option></select></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">What days are you available for services? (Select all that apply)</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Sunday">Sunday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Monday">Monday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Tuesday">Tuesday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Wednesday">Wednesday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Thursday">Thursday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Friday">Friday</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_14" value="Saturday">Saturday</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_14" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_14_Other" type="text"></label></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">What time of day would you prefer to meet for services? (Choose any that apply)</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Any Time">Any Time</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Mornings">Mornings</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Afternoons">Afternoons</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Evenings">Evenings</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_15" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_15_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Name_First" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name:</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Name_Last" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name:</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Nickname/ AKA:</label><input name="CST_27" type="text"></li><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 33.3333%;"> <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_5" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Phone_Mobile" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number:</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_EMail" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">E-Mail:</label><input name="CST_4" 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="CustomField_Value_1"> <i class="fa fa-font"></i><label class="er_fld_label">Parent Name:</label><input name="CST_3" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_2"> <i class="fa fa-font"></i><label class="er_fld_label">Parent E-Mail:</label><input name="CST_28" type="text"></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_49" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Legal Guardian Name:</label><input name="CST_50" type="text" value=""></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Legal Guardian E-Mail:</label><input name="CST_51" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Address_Street_1" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Street Address:</label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_Address_Street_2" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Suite/ APT#:</label><input name="CST_8" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" map_to="CC_Address_County" style="width: 20%;" er_fld_condfld="CST_9" er_fld_condvals="er_fld_showif_values=Virginia"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">City/ County:</label><select name="CST_10" class="er_fld_required"><option value="Not Listed">Not Listed</option><option value="Abingdon">Abingdon</option><option value="Accomack">Accomack</option><option value="Albemarle">Albemarle</option><option value="Alberta">Alberta</option><option value="Alexandria">Alexandria</option><option value="Alleghany">Alleghany</option><option value="Altavista">Altavista</option><option value="Amelia">Amelia</option><option value="Amherst">Amherst</option><option value="Appalachia">Appalachia</option><option value="Appomattox">Appomattox</option><option value="Arlington">Arlington</option><option value="Ashland">Ashland</option><option value="Atkins">Atkins</option><option value="Augusta">Augusta</option><option value="Bassett">Bassett</option><option value="Bath">Bath</option><option value="Bedford">Bedford</option><option value="Belle Haven">Belle Haven</option><option value="Berryville">Berryville</option><option value="Big Stone Gap">Big Stone Gap</option><option value="Blacksburg">Blacksburg</option><option value="Blackstone">Blackstone</option><option value="Bland">Bland</option><option value="Bloxom">Bloxom</option><option value="Blue Ridge">Blue Ridge</option><option value="Bluefield">Bluefield</option><option value="Boones Mill">Boones Mill</option><option value="Botetourt">Botetourt</option><option value="Bowling Green">Bowling Green</option><option value="Boyce">Boyce</option><option value="Boydton">Boydton</option><option value="Boykins">Boykins</option><option value="Bridgewater">Bridgewater</option><option value="Bristol">Bristol</option><option value="Broadway">Broadway</option><option value="Brodnax">Brodnax</option><option value="Brookneal">Brookneal</option><option value="Brunswick">Brunswick</option><option value="Buchanan">Buchanan</option><option value="Buckingham">Buckingham</option><option value="Buena Vista">Buena Vista</option><option value="Burke">Burke</option><option value="Burkeville">Burkeville</option><option value="Campbell">Campbell</option><option value="Cana">Cana</option><option value="Cape Charles">Cape Charles</option><option value="Caroline">Caroline</option><option value="Carroll">Carroll</option><option value="Castlewood">Castlewood</option><option value="Cedar Bluff">Cedar Bluff</option><option value="Centreville">Centreville</option><option value="Chantilly">Chantilly</option><option value="Charles City">Charles City</option><option value="Charlotte">Charlotte</option><option value="Charlotte Court House">Charlotte Court House</option><option value="Charlottesville">Charlottesville</option><option value="Chase City">Chase City</option><option value="Cheriton">Cheriton</option><option value="Chesapeake">Chesapeake</option><option value="Chester">Chester</option><option value="Chesterfield">Chesterfield</option><option value="Chilhowie">Chilhowie</option><option value="Chincoteague Island">Chincoteague Island</option><option value="Christiansburg">Christiansburg</option><option value="Claremont">Claremont</option><option value="Clarke">Clarke</option><option value="Clarksville">Clarksville</option><option value="Clifton Forge">Clifton Forge</option><option value="Clinchco">Clinchco</option><option value="Clintwood">Clintwood</option><option value="Cloverdale">Cloverdale</option><option value="Coeburn">Coeburn</option><option value="Collinsville">Collinsville</option><option value="Colonial Beach">Colonial Beach</option><option value="Colonial Heights">Colonial Heights</option><option value="Courtland">Courtland</option><option value="Covington">Covington</option><option value="Craig">Craig</option><option value="Craigsville">Craigsville</option><option value="Crewe">Crewe</option><option value="Crimora">Crimora</option><option value="Crozet">Crozet</option><option value="Culpeper">Culpeper</option><option value="Cumberland">Cumberland</option><option value="Dahlgren">Dahlgren</option><option value="Daleville">Daleville</option><option value="Damascus">Damascus</option><option value="Danville">Danville</option><option value="Dayton">Dayton</option><option value="Dendron">Dendron</option><option value="Dickenson">Dickenson</option><option value="Dillwyn">Dillwyn</option><option value="Dinwiddie">Dinwiddie</option><option value="Drakes Branch">Drakes Branch</option><option value="Dryden">Dryden</option><option value="Dublin">Dublin</option><option value="Dumfries">Dumfries</option><option value="Dungannon">Dungannon</option><option value="Dunn Loring">Dunn Loring</option><option value="Eastville">Eastville</option><option value="Edinburg">Edinburg</option><option value="Elkton">Elkton</option><option value="Emory">Emory</option><option value="Emporia">Emporia</option><option value="Essex">Essex</option><option value="Ewing">Ewing</option><option value="Exmore">Exmore</option><option value="Fairfax">Fairfax</option><option value="Falls Church">Falls Church</option><option value="Fancy Gap">Fancy Gap</option><option value="Farmville">Farmville</option><option value="Fauquier">Fauquier</option><option value="Ferrum">Ferrum</option><option value="Fieldale">Fieldale</option><option value="Fincastle">Fincastle</option><option value="Fishersville">Fishersville</option><option value="Floyd">Floyd</option><option value="Fluvanna">Fluvanna</option><option value="Forest">Forest</option><option value="Fort Belvoir">Fort Belvoir</option><option value="Franconia">Franconia</option><option value="Franklin">Franklin</option><option value="Frederick">Frederick</option><option value="Fredericksburg">Fredericksburg</option><option value="Fries">Fries</option><option value="Front Royal">Front Royal</option><option value="Galax">Galax</option><option value="Gate City">Gate City</option><option value="Giles">Giles</option><option value="Glade Spring">Glade Spring</option><option value="Glasgow">Glasgow</option><option value="Glen Allen">Glen Allen</option><option value="Glen Lyn">Glen Lyn</option><option value="Gloucester">Gloucester</option><option value="Gloucester Courthouse">Gloucester Courthouse</option><option value="Gloucester Point">Gloucester Point</option><option value="Goochland">Goochland</option><option value="Gordonsville">Gordonsville</option><option value="Goshen">Goshen</option><option value="Grayson">Grayson</option><option value="Great Falls">Great Falls</option><option value="Greene">Greene</option><option value="Greensville">Greensville</option><option value="Gretna">Gretna</option><option value="Grottoes">Grottoes</option><option value="Grundy">Grundy</option><option value="Halifax">Halifax</option><option value="Hamilton">Hamilton</option><option value="Hampton">Hampton</option><option value="Hanover">Hanover</option><option value="Harrisonburg">Harrisonburg</option><option value="Haymarket">Haymarket</option><option value="Haysi">Haysi</option><option value="Henrico">Henrico</option><option value="Henry">Henry</option><option value="Herndon">Herndon</option><option value="Highland">Highland</option><option value="Highland Springs">Highland Springs</option><option value="Hillsboro">Hillsboro</option><option value="Hillsville">Hillsville</option><option value="Honaker">Honaker</option><option value="Hopewell">Hopewell</option><option value="Huntington">Huntington</option><option value="Hurt">Hurt</option><option value="Hybla Valley">Hybla Valley</option><option value="Independence">Independence</option><option value="Iron Gate">Iron Gate</option><option value="Irvington">Irvington</option><option value="Ivor">Ivor</option><option value="Isle of Wight">Isle of Wight</option><option value="James City">James City</option><option value="Jarratt">Jarratt</option><option value="Jefferson">Jefferson</option><option value="Jolivue">Jolivue</option><option value="Jonesville">Jonesville</option><option value="Keller">Keller</option><option value="Kenbridge">Kenbridge</option><option value="Keokee">Keokee</option><option value="Keysville">Keysville</option><option value="Kilmarnock">Kilmarnock</option><option value="King and Queen">King and Queen</option><option value="King George">King George</option><option value="King William">King William</option><option value="La Crosse">La Crosse</option><option value="Lake Monticello">Lake Monticello</option><option value="Lakeside">Lakeside</option><option value="Lancaster">Lancaster</option><option value="Lawrenceville">Lawrenceville</option><option value="Lebanon">Lebanon</option><option value="Lee">Lee</option><option value="Leesburg">Leesburg</option><option value="Lexington">Lexington</option><option value="Lorton">Lorton</option><option value="Loudoun">Loudoun</option><option value="Louisa">Louisa</option><option value="Lovettsville">Lovettsville</option><option value="Lunenburg">Lunenburg</option><option value="Luray">Luray</option><option value="Lynchburg">Lynchburg</option><option value="Madison">Madison</option><option value="Madison Heights">Madison Heights</option><option value="Manassas">Manassas</option><option value="Manassas Park">Manassas Park</option><option value="Marion">Marion</option><option value="Martinsville">Martinsville</option><option value="Matthews">Matthews</option><option value="Mechanicsville">Mechanicsville</option><option value="Middlesex">Middlesex</option><option value="Middletown">Middletown</option><option value="Midlothian">Midlothian</option><option value="Mineral">Mineral</option><option value="Monterey">Monterey</option><option value="Montgomery">Montgomery</option><option value="Montross">Montross</option><option value="Narrows">Narrows</option><option value="Nelson">Nelson</option><option value="New Kent">New Kent</option><option value="Newport News">Newport News</option><option value="Norfolk">Norfolk</option><option value="Northampton">Northampton</option><option value="Northumberland">Northumberland</option><option value="Norton">Norton</option><option value="Nottoway">Nottoway</option><option value="Occoquan">Occoquan</option><option value="Onancock">Onancock</option><option value="Orange">Orange</option><option value="Page">Page</option><option value="Patrick">Patrick</option><option value="Petersburg">Petersburg</option><option value="Pittsylvania">Pittsylvania</option><option value="Poquoson">Poquoson</option><option value="Portsmouth">Portsmouth</option><option value="Powhatan">Powhatan</option><option value="Prince Edward">Prince Edward</option><option value="Prince George">Prince George</option><option value="Prince William">Prince William</option><option value="Pulaski">Pulaski</option><option value="Radford">Radford</option><option value="Rappahannock">Rappahannock</option><option value="Richmond">Richmond</option><option value="Richmond City">Richmond City</option><option value="Roanoke">Roanoke</option><option value="Roanoke City">Roanoke City</option><option value="Rockbridge">Rockbridge</option><option value="Rockingham">Rockingham</option><option value="Rocky Mount">Rocky Mount</option><option value="Russell">Russell</option><option value="Salem">Salem</option><option value="Scott">Scott</option><option value="Shenandoah">Shenandoah</option><option value="Smithfield">Smithfield</option><option value="Smyth">Smyth</option><option value="Southampton">Southampton</option><option value="South Boston">South Boston</option><option value="South Hill">South Hill</option><option value="Spotsylvania">Spotsylvania</option><option value="Spotsylvania Courthouse">Spotsylvania Courthouse</option><option value="Springfield">Springfield</option><option value="Stafford">Stafford</option><option value="Staunton">Staunton</option><option value="Stephens City">Stephens City</option><option value="Strasburg">Strasburg</option><option value="Stuart">Stuart</option><option value="Suffolk">Suffolk</option><option value="Surry">Surry</option><option value="Sussex">Sussex</option><option value="Tappahannock">Tappahannock</option><option value="Tazewell">Tazewell</option><option value="Timberville">Timberville</option><option value="Toms Brook">Toms Brook</option><option value="Triangle">Triangle</option><option value="Troutville">Troutville</option><option value="Urbanna">Urbanna</option><option value="Victoria">Victoria</option><option value="Vienna">Vienna</option><option value="Vinton">Vinton</option><option value="Virginia Beach">Virginia Beach</option><option value="Warren">Warren</option><option value="Warrenton">Warrenton</option><option value="Warsaw">Warsaw</option><option value="Washington">Washington</option><option value="Waynesboro">Waynesboro</option><option value="Westmoreland">Westmoreland</option><option value="West Point">West Point</option><option value="Williamsburg">Williamsburg</option><option value="Winchester">Winchester</option><option value="Windsor">Windsor</option><option value="Wise">Wise</option><option value="Woodstock">Woodstock</option><option value="Wythe">Wythe</option><option value="Wytheville">Wytheville</option><option value="York">York</option><option value="Yorktown">Yorktown</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" map_to="CC_Address_County" style="width: 20%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Not+Listed"> <i class="fa fa-font"></i><label class="er_fld_label required">City/ County:</label><input name="CST_52" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_9" er_fld_condvals="er_fld_showif_values=Alabama&er_fld_showif_values=Alaska&er_fld_showif_values=Arizona&er_fld_showif_values=Arkansas&er_fld_showif_values=California&er_fld_showif_values=Colorado&er_fld_showif_values=Connecticut&er_fld_showif_values=Delaware&er_fld_showif_values=Florida&er_fld_showif_values=Georgia&er_fld_showif_values=Hawaii&er_fld_showif_values=Idaho&er_fld_showif_values=Illinois&er_fld_showif_values=Indiana&er_fld_showif_values=Iowa&er_fld_showif_values=Kansas&er_fld_showif_values=Kentucky&er_fld_showif_values=Louisiana&er_fld_showif_values=Maine&er_fld_showif_values=Maryland&er_fld_showif_values=Massachusetts&er_fld_showif_values=Michigan&er_fld_showif_values=Minnesota&er_fld_showif_values=Mississippi&er_fld_showif_values=Missouri&er_fld_showif_values=Montana&er_fld_showif_values=Nebraska&er_fld_showif_values=Nevada&er_fld_showif_values=New+Hampshire&er_fld_showif_values=New+Jersey&er_fld_showif_values=New+Mexico&er_fld_showif_values=New+York&er_fld_showif_values=North+Carolina&er_fld_showif_values=North+Dakota&er_fld_showif_values=Ohio&er_fld_showif_values=Oklahoma&er_fld_showif_values=Oregon&er_fld_showif_values=Pennsylvania&er_fld_showif_values=Rhode+Island&er_fld_showif_values=South+Carolina&er_fld_showif_values=South+Dakota&er_fld_showif_values=Tennessee&er_fld_showif_values=Texas&er_fld_showif_values=Utah&er_fld_showif_values=Vermont&er_fld_showif_values=Washington&er_fld_showif_values=West+Virginia&er_fld_showif_values=Wisconsin&er_fld_showif_values=Wyoming"> <i class="fa fa-font"></i><label class="er_fld_label required">City/ County:</label><input name="CST_29" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Address_State" style="width: 20%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">State:</label><select name="CST_9" class="er_fld_required"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia" selected="">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_number" draggable="false" style="width: 20%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_11" type="text" class="er_fld_required"></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_9" er_fld_condvals="er_fld_showif_values=Alabama&er_fld_showif_values=Alaska&er_fld_showif_values=Arizona&er_fld_showif_values=Arkansas&er_fld_showif_values=California&er_fld_showif_values=Colorado&er_fld_showif_values=Connecticut&er_fld_showif_values=Delaware&er_fld_showif_values=Florida&er_fld_showif_values=Georgia&er_fld_showif_values=Hawaii&er_fld_showif_values=Idaho&er_fld_showif_values=Illinois&er_fld_showif_values=Indiana&er_fld_showif_values=Iowa&er_fld_showif_values=Kansas&er_fld_showif_values=Kentucky&er_fld_showif_values=Louisiana&er_fld_showif_values=Maine&er_fld_showif_values=Maryland&er_fld_showif_values=Massachusetts&er_fld_showif_values=Michigan&er_fld_showif_values=Minnesota&er_fld_showif_values=Mississippi&er_fld_showif_values=Missouri&er_fld_showif_values=Montana&er_fld_showif_values=Nebraska&er_fld_showif_values=Nevada&er_fld_showif_values=New+Hampshire&er_fld_showif_values=New+Jersey&er_fld_showif_values=New+Mexico&er_fld_showif_values=New+York&er_fld_showif_values=North+Carolina&er_fld_showif_values=North+Dakota&er_fld_showif_values=Ohio&er_fld_showif_values=Oklahoma&er_fld_showif_values=Oregon&er_fld_showif_values=Pennsylvania&er_fld_showif_values=Rhode+Island&er_fld_showif_values=South+Carolina&er_fld_showif_values=South+Dakota&er_fld_showif_values=Tennessee&er_fld_showif_values=Texas&er_fld_showif_values=Utah&er_fld_showif_values=Vermont&er_fld_showif_values=Washington&er_fld_showif_values=West+Virginia&er_fld_showif_values=Wisconsin&er_fld_showif_values=Wyoming"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Most services are provided within the state of Virginia. If your service request is not compatible with telehealth, we may not be able to assist you at this time.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_Gender"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender Assigned at Birth:</label><select name="CST_20" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" 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 er_fld_required" type="radio" name="CST_22" value="Caucasian">Caucasian</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_22" value="African American">African American</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_22" value="Asian/Pacific Islander">Asian/Pacific Islander</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_22" value="Biracial">Biracial</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_22" value="Hispanic">Hispanic</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_22" value="Native American">Native American</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_22" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_22_Other" type="text"></label></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 list all currently prescribed medications:</label><textarea name="CST_30" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What current mental health services are in place (targeted case management, psychiatric care, individual therapy, etc.)?</label><textarea name="CST_31" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is there any current involvement in the judicial system (CHINS, truancy, probation, etc.)?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_33" 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_33" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_33_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_33" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe below:</label><textarea name="CST_32" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How can we help?</label><textarea name="CST_18" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Payment Information</label><hr></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">Payment Method:</label><select name="CST_23" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Self-Pay">Self-Pay</option><option value="Insurance">Insurance</option><option value="Medicaid">Medicaid</option><option value="Other (Ex. CSA, EBA, AMI, or other funded method)">Other (Ex. CSA, EBA, AMI, or other funded method)</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Other+(Ex.+CSA%2C+EBA%2C+AMI%2C+or+other+funded+method)"> <i class="fa fa-font"></i><label class="er_fld_label required">Please Specify Other Payment Method:</label><input name="CST_24" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Medicaid" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Some services are not accessible through Medicaid Currently, Medicaid will cover the following services: Intensive In-Home Community Stabilization (Crisis Stabilization) Mental Health Skill Building If you've selected one of those services, our team will reach out to you to discuss alternative financial support and funding.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Medicaid" style="width: 50%;" map_to="CC_Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Medicaid #:</label><input name="CST_48" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Insurance" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Insurance Company:</label><input name="CST_25" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Insurance" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Policy Number:</label><input name="CST_26" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 50%;"><i class="fa fa-header"></i><label>Referring Worker Information</label><hr></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_12" er_fld_condvals="er_fld_showif_values=My+Client" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Name:</label><input name="CST_16" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-font"></i><label class="er_fld_label required">Credentials:</label><input name="CST_34" type="text" class="er_fld_required"></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_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-font"></i><label class="er_fld_label required">Organization:</label><input name="CST_17" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-font"></i><label class="er_fld_label required">E-Mail:</label><input name="CST_40" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_41" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Fax:</label><input name="CST_42" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Street Address:</label><input name="CST_35" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Suite/ Office#:</label><input name="CST_36" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">City/ County:</label><select name="CST_37" class="er_fld_required"><option value="Not Listed">Not Listed</option><option value="Abingdon">Abingdon</option><option value="Accomack">Accomack</option><option value="Albemarle">Albemarle</option><option value="Alberta">Alberta</option><option value="Alexandria">Alexandria</option><option value="Alleghany">Alleghany</option><option value="Altavista">Altavista</option><option value="Amelia">Amelia</option><option value="Amherst">Amherst</option><option value="Appalachia">Appalachia</option><option value="Appomattox">Appomattox</option><option value="Arlington">Arlington</option><option value="Ashland">Ashland</option><option value="Atkins">Atkins</option><option value="Augusta">Augusta</option><option value="Bassett">Bassett</option><option value="Bath">Bath</option><option value="Bedford">Bedford</option><option value="Belle Haven">Belle Haven</option><option value="Berryville">Berryville</option><option value="Big Stone Gap">Big Stone Gap</option><option value="Blacksburg">Blacksburg</option><option value="Blackstone">Blackstone</option><option value="Bland">Bland</option><option value="Bloxom">Bloxom</option><option value="Blue Ridge">Blue Ridge</option><option value="Bluefield">Bluefield</option><option value="Boones Mill">Boones Mill</option><option value="Botetourt">Botetourt</option><option value="Bowling Green">Bowling Green</option><option value="Boyce">Boyce</option><option value="Boydton">Boydton</option><option value="Boykins">Boykins</option><option value="Bridgewater">Bridgewater</option><option value="Bristol">Bristol</option><option value="Broadway">Broadway</option><option value="Brodnax">Brodnax</option><option value="Brookneal">Brookneal</option><option value="Brunswick">Brunswick</option><option value="Buchanan">Buchanan</option><option value="Buckingham">Buckingham</option><option value="Buena Vista">Buena Vista</option><option value="Burke">Burke</option><option value="Burkeville">Burkeville</option><option value="Campbell">Campbell</option><option value="Cana">Cana</option><option value="Cape Charles">Cape Charles</option><option value="Caroline">Caroline</option><option value="Carroll">Carroll</option><option value="Castlewood">Castlewood</option><option value="Cedar Bluff">Cedar Bluff</option><option value="Centreville">Centreville</option><option value="Chantilly">Chantilly</option><option value="Charles City">Charles City</option><option value="Charlotte">Charlotte</option><option value="Charlotte Court House">Charlotte Court House</option><option value="Charlottesville">Charlottesville</option><option value="Chase City">Chase City</option><option value="Cheriton">Cheriton</option><option value="Chesapeake">Chesapeake</option><option value="Chester">Chester</option><option value="Chesterfield">Chesterfield</option><option value="Chilhowie">Chilhowie</option><option value="Chincoteague Island">Chincoteague Island</option><option value="Christiansburg">Christiansburg</option><option value="Claremont">Claremont</option><option value="Clarke">Clarke</option><option value="Clarksville">Clarksville</option><option value="Clifton Forge">Clifton Forge</option><option value="Clinchco">Clinchco</option><option value="Clintwood">Clintwood</option><option value="Cloverdale">Cloverdale</option><option value="Coeburn">Coeburn</option><option value="Collinsville">Collinsville</option><option value="Colonial Beach">Colonial Beach</option><option value="Colonial Heights">Colonial Heights</option><option value="Courtland">Courtland</option><option value="Covington">Covington</option><option value="Craig">Craig</option><option value="Craigsville">Craigsville</option><option value="Crewe">Crewe</option><option value="Crimora">Crimora</option><option value="Crozet">Crozet</option><option value="Culpeper">Culpeper</option><option value="Cumberland">Cumberland</option><option value="Dahlgren">Dahlgren</option><option value="Daleville">Daleville</option><option value="Damascus">Damascus</option><option value="Danville">Danville</option><option value="Dayton">Dayton</option><option value="Dendron">Dendron</option><option value="Dickenson">Dickenson</option><option value="Dillwyn">Dillwyn</option><option value="Dinwiddie">Dinwiddie</option><option value="Drakes Branch">Drakes Branch</option><option value="Dryden">Dryden</option><option value="Dublin">Dublin</option><option value="Dumfries">Dumfries</option><option value="Dungannon">Dungannon</option><option value="Dunn Loring">Dunn Loring</option><option value="Eastville">Eastville</option><option value="Edinburg">Edinburg</option><option value="Elkton">Elkton</option><option value="Emory">Emory</option><option value="Emporia">Emporia</option><option value="Essex">Essex</option><option value="Ewing">Ewing</option><option value="Exmore">Exmore</option><option value="Fairfax">Fairfax</option><option value="Falls Church">Falls Church</option><option value="Fancy Gap">Fancy Gap</option><option value="Farmville">Farmville</option><option value="Fauquier">Fauquier</option><option value="Ferrum">Ferrum</option><option value="Fieldale">Fieldale</option><option value="Fincastle">Fincastle</option><option value="Fishersville">Fishersville</option><option value="Floyd">Floyd</option><option value="Fluvanna">Fluvanna</option><option value="Forest">Forest</option><option value="Fort Belvoir">Fort Belvoir</option><option value="Franconia">Franconia</option><option value="Franklin">Franklin</option><option value="Frederick">Frederick</option><option value="Fredericksburg">Fredericksburg</option><option value="Fries">Fries</option><option value="Front Royal">Front Royal</option><option value="Galax">Galax</option><option value="Gate City">Gate City</option><option value="Giles">Giles</option><option value="Glade Spring">Glade Spring</option><option value="Glasgow">Glasgow</option><option value="Glen Allen">Glen Allen</option><option value="Glen Lyn">Glen Lyn</option><option value="Gloucester">Gloucester</option><option value="Gloucester Courthouse">Gloucester Courthouse</option><option value="Gloucester Point">Gloucester Point</option><option value="Goochland">Goochland</option><option value="Gordonsville">Gordonsville</option><option value="Goshen">Goshen</option><option value="Grayson">Grayson</option><option value="Great Falls">Great Falls</option><option value="Greene">Greene</option><option value="Greensville">Greensville</option><option value="Gretna">Gretna</option><option value="Grottoes">Grottoes</option><option value="Grundy">Grundy</option><option value="Halifax">Halifax</option><option value="Hamilton">Hamilton</option><option value="Hampton">Hampton</option><option value="Hanover">Hanover</option><option value="Harrisonburg">Harrisonburg</option><option value="Haymarket">Haymarket</option><option value="Haysi">Haysi</option><option value="Henrico">Henrico</option><option value="Henry">Henry</option><option value="Herndon">Herndon</option><option value="Highland">Highland</option><option value="Highland Springs">Highland Springs</option><option value="Hillsboro">Hillsboro</option><option value="Hillsville">Hillsville</option><option value="Honaker">Honaker</option><option value="Hopewell">Hopewell</option><option value="Huntington">Huntington</option><option value="Hurt">Hurt</option><option value="Hybla Valley">Hybla Valley</option><option value="Independence">Independence</option><option value="Iron Gate">Iron Gate</option><option value="Irvington">Irvington</option><option value="Ivor">Ivor</option><option value="Isle of Wight">Isle of Wight</option><option value="James City">James City</option><option value="Jarratt">Jarratt</option><option value="Jefferson">Jefferson</option><option value="Jolivue">Jolivue</option><option value="Jonesville">Jonesville</option><option value="Keller">Keller</option><option value="Kenbridge">Kenbridge</option><option value="Keokee">Keokee</option><option value="Keysville">Keysville</option><option value="Kilmarnock">Kilmarnock</option><option value="King and Queen">King and Queen</option><option value="King George">King George</option><option value="King William">King William</option><option value="La Crosse">La Crosse</option><option value="Lake Monticello">Lake Monticello</option><option value="Lakeside">Lakeside</option><option value="Lancaster">Lancaster</option><option value="Lawrenceville">Lawrenceville</option><option value="Lebanon">Lebanon</option><option value="Lee">Lee</option><option value="Leesburg">Leesburg</option><option value="Lexington">Lexington</option><option value="Lorton">Lorton</option><option value="Loudoun">Loudoun</option><option value="Louisa">Louisa</option><option value="Lovettsville">Lovettsville</option><option value="Lunenburg">Lunenburg</option><option value="Luray">Luray</option><option value="Lynchburg">Lynchburg</option><option value="Madison">Madison</option><option value="Madison Heights">Madison Heights</option><option value="Manassas">Manassas</option><option value="Manassas Park">Manassas Park</option><option value="Marion">Marion</option><option value="Martinsville">Martinsville</option><option value="Matthews">Matthews</option><option value="Mechanicsville">Mechanicsville</option><option value="Middlesex">Middlesex</option><option value="Middletown">Middletown</option><option value="Midlothian">Midlothian</option><option value="Mineral">Mineral</option><option value="Monterey">Monterey</option><option value="Montgomery">Montgomery</option><option value="Montross">Montross</option><option value="Narrows">Narrows</option><option value="Nelson">Nelson</option><option value="New Kent">New Kent</option><option value="Newport News">Newport News</option><option value="Norfolk">Norfolk</option><option value="Northampton">Northampton</option><option value="Northumberland">Northumberland</option><option value="Norton">Norton</option><option value="Nottoway">Nottoway</option><option value="Occoquan">Occoquan</option><option value="Onancock">Onancock</option><option value="Orange">Orange</option><option value="Page">Page</option><option value="Patrick">Patrick</option><option value="Petersburg">Petersburg</option><option value="Pittsylvania">Pittsylvania</option><option value="Poquoson">Poquoson</option><option value="Portsmouth">Portsmouth</option><option value="Powhatan">Powhatan</option><option value="Prince Edward">Prince Edward</option><option value="Prince George">Prince George</option><option value="Prince William">Prince William</option><option value="Pulaski">Pulaski</option><option value="Radford">Radford</option><option value="Rappahannock">Rappahannock</option><option value="Richmond">Richmond</option><option value="Richmond City">Richmond City</option><option value="Roanoke">Roanoke</option><option value="Roanoke City">Roanoke City</option><option value="Rockbridge">Rockbridge</option><option value="Rockingham">Rockingham</option><option value="Rocky Mount">Rocky Mount</option><option value="Russell">Russell</option><option value="Salem">Salem</option><option value="Scott">Scott</option><option value="Shenandoah">Shenandoah</option><option value="Smithfield">Smithfield</option><option value="Smyth">Smyth</option><option value="Southampton">Southampton</option><option value="South Boston">South Boston</option><option value="South Hill">South Hill</option><option value="Spotsylvania">Spotsylvania</option><option value="Spotsylvania Courthouse">Spotsylvania Courthouse</option><option value="Springfield">Springfield</option><option value="Stafford">Stafford</option><option value="Staunton">Staunton</option><option value="Stephens City">Stephens City</option><option value="Strasburg">Strasburg</option><option value="Stuart">Stuart</option><option value="Suffolk">Suffolk</option><option value="Surry">Surry</option><option value="Sussex">Sussex</option><option value="Tappahannock">Tappahannock</option><option value="Tazewell">Tazewell</option><option value="Timberville">Timberville</option><option value="Toms Brook">Toms Brook</option><option value="Triangle">Triangle</option><option value="Troutville">Troutville</option><option value="Urbanna">Urbanna</option><option value="Victoria">Victoria</option><option value="Vienna">Vienna</option><option value="Vinton">Vinton</option><option value="Virginia Beach">Virginia Beach</option><option value="Warren">Warren</option><option value="Warrenton">Warrenton</option><option value="Warsaw">Warsaw</option><option value="Washington">Washington</option><option value="Waynesboro">Waynesboro</option><option value="Westmoreland">Westmoreland</option><option value="West Point">West Point</option><option value="Williamsburg">Williamsburg</option><option value="Winchester">Winchester</option><option value="Windsor">Windsor</option><option value="Wise">Wise</option><option value="Woodstock">Woodstock</option><option value="Wythe">Wythe</option><option value="Wytheville">Wytheville</option><option value="York">York</option><option value="Yorktown">Yorktown</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_37" er_fld_condvals="er_fld_showif_values=Not+Listed" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City/ County:</label><input name="CST_53" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">State:</label><select name="CST_38" class="er_fld_required"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia" selected="">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_39" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 50%;"><i class="fa fa-header"></i><label>Presenting Problem</label><hr></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_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Guidance Please describe the reason for referral including frequency, intensity, and duration of behaviors over the past 30 days.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Behaviors that put the individual at risk of out-of-home placement, in personal danger, substance use, and/or are significantly socially inappropriate:</label><textarea name="CST_43" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Behaviors that display deficits in social skills and/or dealing with authority, hyperactivity, poor impulse control, signs of extreme depression, signs of being marginally connected with reality:</label><textarea name="CST_44" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col4 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_12" er_fld_condvals="er_fld_showif_values=My+Client"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">In the past, has the client received any of the following services (check all that apply):</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="23-Hour Crisis Stabilization">23-Hour Crisis Stabilization</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Acute Psychiatric Inpatient Services">Acute Psychiatric Inpatient Services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="ASAM Level 3.1-4.0">ASAM Level 3.1-4.0</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="CSB Emergency Services">CSB Emergency Services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Hospital Emergency Department">Hospital Emergency Department</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Mobile Crisis Response">Mobile Crisis Response</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Partial Hospitalization Program (Mental Health or ARTS)">Partial Hospitalization Program (Mental Health or ARTS)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Psychiatric Residential Treatment Facility (Mental Health or ARTS)">Psychiatric Residential Treatment Facility (Mental Health or ARTS)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Residential Crisis Stabilization Unit">Residential Crisis Stabilization Unit</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Short-term detention or incarceration">Short-term detention or incarceration</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Therapeutic Group Home">Therapeutic Group Home</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="None of the above">None of the above</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_large" draggable="false" er_fld_condfld="CST_45" er_fld_condvals="er_fld_showif_values=23-Hour+Crisis+Stabilization&er_fld_showif_values=Acute+Psychiatric+Inpatient+Services&er_fld_showif_values=ASAM+Level+3.1-4.0&er_fld_showif_values=CSB+Emergency+Services&er_fld_showif_values=Hospital+Emergency+Department&er_fld_showif_values=Mobile+Crisis+Response&er_fld_showif_values=Partial+Hospitalization+Program+(Mental+Health+or+ARTS)&er_fld_showif_values=Psychiatric+Residential+Treatment+Facility+(Mental+Health+or+ARTS)&er_fld_showif_values=Residential+Crisis+Stabilization+Unit&er_fld_showif_values=Short-term+detention+or+incarceration&er_fld_showif_values=Therapeutic+Group+Home" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If any of the above services were utilized in the past, please provide a brief description below (please include dates if possible):</label><textarea name="CST_46" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul id="er_row_last" class="er_fld_row"><li class="er_fld_type_content er_fld_selected" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">10DLC Compliance Statement: By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging. See our Privacy Policy for more information.</div></li></ul>
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