Online Referral

Click the 'Generate Form' link to pre-populate the form when you are ready.

<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_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 filling this form out for:</label>

<label class="er_option"><input class="type_radio" type="radio" name="CST_61" value="Myself">Myself</label><label class="er_option"><input class="type_radio" type="radio" name="CST_61" value="My Child">My Child</label><label class="er_option"><input class="type_radio" type="radio" name="CST_61" 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_61" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_61_Other" type="text"></label></li><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_61" er_fld_condvals="er_fld_showif_values=My+Child&amp;er_fld_showif_values=My+Client"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you their legal guardian?</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_64" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_64" 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 er_fld_blank" type="radio" name="CST_64" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_64_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=My+Child">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">Please use your child's legal first and last name below.</div></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_61" 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 er_fld_noprint">Please use your client's legal first and last name below.</div></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">First Name:</label><input name="CST_2" type="text" class="er_fld_required" fdprocessedid="mthof3"></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">Last Name:</label><input name="CST_3" type="text" class="er_fld_required" fdprocessedid="gyp9m4"></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">Nickname/ AKA:</label><input name="CST_59" type="text" class="er_fld_blank" fdprocessedid="2pyco"></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:</label><input name="CST_6" type="text" class="er_fld_required" fdprocessedid="z79bt"></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_5" type="text" class="er_fld_required" fdprocessedid="86q1x"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Gender" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender Assigned At Birth:</label><select name="CST_16" class="er_fld_required" fdprocessedid="r9rxn"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Race" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Race:</label><select name="CST_17" class="er_fld_required" fdprocessedid="22yq05"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Caucasian">Caucasian</option><option value="Unknown">Unknown</option><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Biracial">Biracial</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><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_27" type="text" fdprocessedid="1a945f"></li><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/ Legal Guardian Name (First and Last)</label><input name="CST_4" type="text" fdprocessedid="yygvjn" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Preferred Location (Counseling):</label><select name="CST_12" class="er_fld_required" fdprocessedid="xdm8rl"><option value="- Not Specified -">- Not Specified -</option><option value="Bedford" selected="">Bedford</option><option value="Fairfax">Fairfax</option><option value="Harrisonburg">Harrisonburg</option><option value="Lynchburg ">Lynchburg </option><option value="Roanoke">Roanoke</option><option value="Virginia Beach">Virginia Beach</option><option value="Telehealth">Telehealth</option><option value="Appomattox">Appomattox</option></select></li><li class="er_fld_type_radio er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do you prefer telehealth?</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_desc" type="radio" name="CST_18" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_desc" type="radio" name="CST_18" 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 er_fld_desc" type="radio" name="CST_18" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_18_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Address_Street_1" style="width: 50%;">
<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" fdprocessedid="ynftx"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Address_Street_2" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Apt/ Suite#</label><input name="CST_8" type="text" fdprocessedid="i7kuj" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;" map_to="CC_Address_City">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">City/ County:</label><select name="CST_9" class="er_fld_required" fdprocessedid="qi72yk"><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_9" er_fld_condvals="er_fld_showif_values=Not+Listed" style="width: 20%;" map_to="CC_Address_City">
<i class="fa fa-font"></i><label class="er_fld_label required">City/County:</label><input name="CST_62" type="text" class="er_fld_required" fdprocessedid="207tzm"></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_10" class="er_fld_required" fdprocessedid="19691m"><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%;" map_to="CC_Address_Zip">
<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" fdprocessedid="3z668e"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling" 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_radio er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling"><i class="fa fa-circle-o"></i><label class="er_fld_label required">How will services be paid?</label>

<label class="er_option"><input class="type_radio er_fld_desc" type="radio" name="CST_58" value="Self-Pay">Self-Pay</label><label class="er_option"><input class="type_radio er_fld_desc" type="radio" name="CST_58" value="Insurance">Insurance</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_desc" type="radio" name="CST_58" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" name="CST_58_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_58" er_fld_condvals="er_fld_showif_values=Self-Pay" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">Self Pay Information
Self pay rates for various providers range from $60-$100. Please see provider profile for more details.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.333333333333336%;" er_fld_condfld="CST_58" er_fld_condvals="er_fld_showif_values=Insurance">
<i class="fa fa-font"></i><label class="er_fld_label required">Insurance Company:</label><input name="CST_14" type="text" class="er_fld_required er_fld_blank" fdprocessedid="fcc45o"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.333333333333336%;" er_fld_condfld="CST_58" er_fld_condvals="er_fld_showif_values=Insurance" map_to="CC_Medicaid">
<i class="fa fa-font"></i><label class="er_fld_label required">Insurance/ Medicaid Number:</label><input name="CST_15" type="text" class="er_fld_required er_fld_blank" fdprocessedid="45i23w"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_58" er_fld_condvals="er_fld_showif_values=Insurance"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are there any additional health insurance policies for this person? </label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_66" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_66" 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 er_fld_blank" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_66_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.333333333333336%;" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label required">Insurance Company</label><input name="CST_67" type="text" class="er_fld_required er_fld_blank" fdprocessedid="7o8s9v"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.333333333333336%;" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label required">Insurance/Medicaid Number</label><input name="CST_68" type="text" class="er_fld_required er_fld_blank" fdprocessedid="5hswrd"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected er_fld_showif" style="white-space: normal; width: 100%;" draggable="false" er_fld_condfld="CST_58" er_fld_condvals="er_fld_showif_values=Insurance"><i class="fa fa-circle-o"></i><label class="er_fld_label required"> Is this a Dual (Medicare/Medicaid) insurance policy?</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_desc er_fld_blank" type="radio" name="CST_69" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_desc er_fld_blank" type="radio" name="CST_69" 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 er_fld_desc er_fld_blank" type="radio" name="CST_69" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc er_fld_blank" name="CST_69_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling&amp;er_fld_showif_values=Sexualized+Behavior+Problems"><i class="fa fa-header"></i><label>General Availability</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 33.333333333333336%;" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling&amp;er_fld_showif_values=Sexualized+Behavior+Problems" map_to="CC_Comments"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Which days of the week are you available for services? (Check all that apply)</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Monday">Monday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Tuesday">Tuesday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Wednesday">Wednesday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Thursday">Thursday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="Friday">Friday</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_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col4" style="white-space: normal; width: 33.333333333333336%;" draggable="false" er_fld_condvals="er_fld_showif_values=Outpatient+Counseling&amp;er_fld_showif_values=Sexualized+Behavior+Problems" map_to="CC_Comments"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What times during the day work best for you? (Check all that apply)</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="9AM">9AM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="10AM">10AM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="11AM">11AM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="12PM">12PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="1PM">1PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="2PM">2PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="3PM">3PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="4PM">4PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="5PM">5PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="6PM">6PM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="7PM">7PM</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_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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Treatment Goals</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">How can we help?</label><textarea name="CST_49" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" er_fld_condvals="er_fld_showif_values=My+Client" style="width: 50%;" er_fld_condfld="CST_61"><i class="fa fa-header"></i><label>Referral Information</label><hr></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_condvals="er_fld_showif_values=My+Client" er_fld_condfld="CST_61" map_to="Nothing"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Referral Source:</label>

<label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Community Service Board">Community Service Board</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Counseling Provider">Counseling Provider</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="DJJ">DJJ</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="DSS">DSS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="EBA">EBA</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Online Web Search">Online Web Search</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Physician/PCP">Physician/PCP</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Self/Family/Friend">Self/Family/Friend</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="School Counselor">School Counselor</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Social Media">Social Media</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Veteran Affairs">Veteran Affairs</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="YWCA">YWCA</label><label class="er_option"><input class="type_radio" type="radio" name="CST_20" value="Impact">Impact</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_20" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_20_Other" type="text" fdprocessedid="o35lps"></label></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_61" 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 of Organization or Person Referring:</label><input name="CST_21" type="text" class="er_fld_required er_fld_blank" fdprocessedid="u9q2rn"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=My+Client" map_to="CC_ReferringPhone_Ref">
<i class="fa fa-font"></i><label class="er_fld_label required">Referral Source Phone Number:</label><input name="CST_22" type="text" class="er_fld_required er_fld_blank" fdprocessedid="p5zdfp"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 25%;" er_fld_condvals="er_fld_showif_values=My+Client" map_to="CC_ReferralSource_Ref">
<i class="fa fa-font"></i><label class="er_fld_label required">Referring Agency:</label><input name="CST_40" type="text" class="er_fld_required er_fld_blank" fdprocessedid="x02n7"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 25%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's Name:</label><input name="CST_41" type="text" class="er_fld_required er_fld_blank" fdprocessedid="0t684"></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 25%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label">Referrer's Credentials:</label><input name="CST_42" type="text" class="er_fld_blank" fdprocessedid="oli7ip"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 33.3333%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's Phone Number:</label><input name="CST_44" type="text" class="er_fld_required er_fld_blank" fdprocessedid="00thz"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's Fax:</label><input name="CST_46" type="text" class="er_fld_required er_fld_blank" fdprocessedid="2bw2l"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 50%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's Email:</label><input name="CST_45" type="text" class="er_fld_required er_fld_blank" fdprocessedid="ixj9l"></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_61" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-font"></i><label class="er_fld_label">Agency Street Address:</label><input name="CST_43" type="text" class="er_fld_blank" fdprocessedid="eq8xwo"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 20%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Agency City/County:</label><select name="CST_47" class="er_fld_blank" fdprocessedid="o58126"><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" style="width: 20%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=Not+Listed">
<i class="fa fa-font"></i><label class="er_fld_label">Agency City/ County:</label><input name="CST_63" type="text" class="er_fld_blank" fdprocessedid="o3kr7r"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" er_fld_condfld="CST_61" style="width: 20%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Agency State:</label><select name="CST_48" class="er_fld_blank" fdprocessedid="8yljmr"><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" er_fld_condfld="CST_61" style="width: 20%;" er_fld_condvals="er_fld_showif_values=My+Client">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Agency Zip Code:</label><input name="CST_60" type="text" class="er_fld_blank" fdprocessedid="3tln8l"></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_RefSecReason_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">How did you hear about Impact Living Services?</label>

<label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Social Media">Social Media</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Web Search">Web Search</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Referral Source">Referral Source</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Friend/Family/Word of Mouth">Friend/Family/Word of Mouth</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Email/Mailer">Email/Mailer</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_24" value="Community Ad">Community Ad</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_24" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_24_Other" type="text" fdprocessedid="oup7ye"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">10DLC Compliance Statement:&nbsp; By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message &amp; data rates may apply. Reply STOP to opt out of further messaging.
See our Privacy Policy for more information.

Please note that, in alignment with our mission to serve at-risk youth throughout Virginia, and in order to best provide services to youth, Impact Living Services is unable to provide Outpatient Counseling services to individuals listed on the sex offender registry.
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