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" type="radio" name="CST_64" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_64" value="No">No</label>
<label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_64" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_64_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_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">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">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"></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"></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=""></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"></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"></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"><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"><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"></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"></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"><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></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"></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"></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"><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"></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"><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"></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">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"></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"></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" type="radio" name="CST_66" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="No">No</label>
<label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_66_Other" type="text"></label>
</li></ul><ul class="er_fld_row"><li class="er_fld_type_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"></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"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><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" type="radio" name="CST_69" value="Yes">Yes</label>
<label class="er_option"><input class="type_radio er_fld_required er_fld_desc" 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" type="radio" name="CST_69" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_desc" 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 er_fld_selected" 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"><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"><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%;">
<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"><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="Caseworker">Caseworker</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="Doctor's Office">Doctor's Office</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="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 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"></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">
<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"></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">Referral Source Phone Number:</label><input name="CST_22" 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_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">Referring Agency:</label><input name="CST_40" type="text" class="er_fld_required"></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"></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=""></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"></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"></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"></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=""></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=""><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=""></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=""><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=""></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">How did you hear about Impact Living Services?</label>

<label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" value="Social Media">Social Media</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" value="Web Search">Web Search</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_24" value="Referral Source">Referral Source</label><label class="er_option"><input class="type_radio er_fld_required" 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" type="radio" name="CST_24" value="Email/Mailer">Email/Mailer</label><label class="er_option"><input class="type_radio er_fld_required" 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" type="radio" name="CST_24" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_24_Other" type="text"></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">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.</div></li></ul>