Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Custodian/ Referral Source Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_ReferringWorker_Ref" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Name:</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" map_to="CC_ReferringPhone_Ref" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">Your Phone:</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 25%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Extension?</label><input name="CST_3" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Email:</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Your Fax:</label><input name="CST_7" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" map_to="CC_ReferralSource_Ref" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Referring Agency:</label><select name="CST_4" class="er_fld_required er_fld_desc"><option value="Not Listed">Not Listed</option><option value="Accomack DSS (Accomack)">Accomack DSS (Accomack)</option><option value="Albemarle DSS (Charlottesville)">Albemarle DSS (Charlottesville)</option><option value="Alexandria DSS (Alexandria)">Alexandria DSS (Alexandria)</option><option value="Alleghany-Covington DSS (Covington)">Alleghany-Covington DSS (Covington)</option><option value="Amelia DSS (Amelia)">Amelia DSS (Amelia)</option><option value="Amherst DSS (Amherst)">Amherst DSS (Amherst)</option><option value="Appomattox DSS (Appomattox)">Appomattox DSS (Appomattox)</option><option value="Arlington DSS (Arlington)">Arlington DSS (Arlington)</option><option value="Bath DSS (Warm Springs)">Bath DSS (Warm Springs)</option><option value="Bedford DSS (Bedford)">Bedford DSS (Bedford)</option><option value="Bland DSS (Bland)">Bland DSS (Bland)</option><option value="Botetourt DSS (Daleville)">Botetourt DSS (Daleville)</option><option value="Bristol City DSS (Bristol)">Bristol City DSS (Bristol)</option><option value="Brunswick DSS (Lawrenceville)">Brunswick DSS (Lawrenceville)</option><option value="Buchanan DSS (Grundy)">Buchanan DSS (Grundy)</option><option value="Buckingham DSS (Buckingham)">Buckingham DSS (Buckingham)</option><option value="Campbell DSS (Rustburg)">Campbell DSS (Rustburg)</option><option value="Caroline DSS (Bowling Green)">Caroline DSS (Bowling Green)</option><option value="Carroll DSS (Hillsville)">Carroll DSS (Hillsville)</option><option value="Charles City DSS (Charles City)">Charles City DSS (Charles City)</option><option value="Charlotte DSS (Charlotte)">Charlotte DSS (Charlotte)</option><option value="Charlottesville DSS (Charlottesville)">Charlottesville DSS (Charlottesville)</option><option value="Chesapeake DSS (Chesapeake)">Chesapeake DSS (Chesapeake)</option><option value="Chesterfield-Colonial Heights DSS (Chesterfield)">Chesterfield-Colonial Heights DSS (Chesterfield)</option><option value="Clarke DSS (Berryville)">Clarke DSS (Berryville)</option><option value="Craig DSS (New Castle)">Craig DSS (New Castle)</option><option value="Culpeper DSS (Culpeper)">Culpeper DSS (Culpeper)</option><option value="Cumberland DSS (Cumberland)">Cumberland DSS (Cumberland)</option><option value="Danville DSS (Danville)">Danville DSS (Danville)</option><option value="Dickenson DSS (Clintwood)">Dickenson DSS (Clintwood)</option><option value="Dinwiddie DSS (Dinwiddie)">Dinwiddie DSS (Dinwiddie)</option><option value="Essex DSS (Tappahannock)">Essex DSS (Tappahannock)</option><option value="Fairfax County DSS (Fairfax)">Fairfax County DSS (Fairfax)</option><option value="Fauquier DSS (Warrenton)">Fauquier DSS (Warrenton)</option><option value="Floyd DSS (Floyd)">Floyd DSS (Floyd)</option><option value="Fluvanna DSS (Fork Union)">Fluvanna DSS (Fork Union)</option><option value="Franklin City DSS (Franklin)">Franklin City DSS (Franklin)</option><option value="Franklin County DSS (Rocky Mount)">Franklin County DSS (Rocky Mount)</option><option value="Frederick DSS (Winchester)">Frederick DSS (Winchester)</option><option value="Fredericksburg DSS (Fredericksburg)">Fredericksburg DSS (Fredericksburg)</option><option value="Galax City DSS (Galax)">Galax City DSS (Galax)</option><option value="Giles DSS (Narrows)">Giles DSS (Narrows)</option><option value="Gloucester DSS (Gloucester)">Gloucester DSS (Gloucester)</option><option value="Goochland DSS (Goochland)">Goochland DSS (Goochland)</option><option value="Grayson DSS (Independence)">Grayson DSS (Independence)</option><option value="Greene DSS (Standardsville)">Greene DSS (Standardsville)</option><option value="Greensville-Emporia DSS (Emporia)">Greensville-Emporia DSS (Emporia)</option><option value="Halifax DSS (Halifax)">Halifax DSS (Halifax)</option><option value="Hampton DSS (Hampton)">Hampton DSS (Hampton)</option><option value="Hanover DSS (Ashland)">Hanover DSS (Ashland)</option><option value="Harrisonburg-Rockingham DSS (Harrisonburg)">Harrisonburg-Rockingham DSS (Harrisonburg)</option><option value="Henrico DSS (Henrico)">Henrico DSS (Henrico)</option><option value="Henry-Martinsville DSS (Martinsville)">Henry-Martinsville DSS (Martinsville)</option><option value="Highland DSS (Monterey)">Highland DSS (Monterey)</option><option value="Hopewell DSS (Hopewell)">Hopewell DSS (Hopewell)</option><option value="Isle of Wight DSS (Isle of Wight)">Isle of Wight DSS (Isle of Wight)</option><option value="James City DSS (Williamsburg)">James City DSS (Williamsburg)</option><option value="King and Queen DSS (King and Queen Courthouse)">King and Queen DSS (King and Queen Courthouse)</option><option value="King George DSS (King George)">King George DSS (King George)</option><option value="King William DSS (King William)">King William DSS (King William)</option><option value="Lancaster DSS (Lancaster)">Lancaster DSS (Lancaster)</option><option value="Lee DSS (Jonesville)">Lee DSS (Jonesville)</option><option value="Loudoun DFS (Leesburg)">Loudoun DFS (Leesburg)</option><option value="Louisa DSS (Louisa)">Louisa DSS (Louisa)</option><option value="Lunenburg DSS (Lunenburg)">Lunenburg DSS (Lunenburg)</option><option value="Lynchburg DSS (Lynchburg)">Lynchburg DSS (Lynchburg)</option><option value="Madison DSS (Madison)">Madison DSS (Madison)</option><option value="Manassas City DSS (Manassas)">Manassas City DSS (Manassas)</option><option value="Manassas Park DSS (Manassas)">Manassas Park DSS (Manassas)</option><option value="Mathews DSS (Mathews)">Mathews DSS (Mathews)</option><option value="Mecklenburg DSS (Boydton)">Mecklenburg DSS (Boydton)</option><option value="Middlesex DSS (Urbanna)">Middlesex DSS (Urbanna)</option><option value="Montgomery DSS (Christiansburg)">Montgomery DSS (Christiansburg)</option><option value="Nelson DSS (Lovington)">Nelson DSS (Lovington)</option><option value="New Kent DSS (New Kent)">New Kent DSS (New Kent)</option><option value="Newport News DSS (Newport News)">Newport News DSS (Newport News)</option><option value="Norfolk DSS (Norfolk)">Norfolk DSS (Norfolk)</option><option value="Northampton DSS (Eastville)">Northampton DSS (Eastville)</option><option value="Northumberland DSS (Heathsville)">Northumberland DSS (Heathsville)</option><option value="Norton City DSS (Norton)">Norton City DSS (Norton)</option><option value="Nottoway DSS (Nottoway)">Nottoway DSS (Nottoway)</option><option value="Orange DSS (Orange)">Orange DSS (Orange)</option><option value="Out of State - Tennessee (-)">Out of State - Tennessee (-)</option><option value="Page DSS (Stanley)">Page DSS (Stanley)</option><option value="Patrick DSS (Stuart)">Patrick DSS (Stuart)</option><option value="Petersburg DSS (Petersburg)">Petersburg DSS (Petersburg)</option><option value="Pittsylvania DSS (Chatham)">Pittsylvania DSS (Chatham)</option><option value="Portsmouth DSS (Portsmouth)">Portsmouth DSS (Portsmouth)</option><option value="Powhatan DSS (Powhatan)">Powhatan DSS (Powhatan)</option><option value="Prince Edward DSS (Farmville)">Prince Edward DSS (Farmville)</option><option value="Prince George DSS (Prince George)">Prince George DSS (Prince George)</option><option value="Prince William DSS (Manassas)">Prince William DSS (Manassas)</option><option value="Pulaski DSS (Pulaski)">Pulaski DSS (Pulaski)</option><option value="Radford City DSS (Radford)">Radford City DSS (Radford)</option><option value="Rappahannock DSS (Washington)">Rappahannock DSS (Washington)</option><option value="Richmond City DSS (Richmond)">Richmond City DSS (Richmond)</option><option value="Richmond County DSS (Warsaw)">Richmond County DSS (Warsaw)</option><option value="Roanoke City DSS (Roanoke)">Roanoke City DSS (Roanoke)</option><option value="Roanoke County DSS (Salem)">Roanoke County DSS (Salem)</option><option value="Rockbridge-Buena Vista-Lexington DSS (Lexington)">Rockbridge-Buena Vista-Lexington DSS (Lexington)</option><option value="Russell DSS (Lebanon)">Russell DSS (Lebanon)</option><option value="Scott DSS (Gate City)">Scott DSS (Gate City)</option><option value="Shenandoah County DSS (Woodstock)">Shenandoah County DSS (Woodstock)</option><option value="Shenandoah Valley DSS (Verona)">Shenandoah Valley DSS (Verona)</option><option value="Smyth DSS (Marion)">Smyth DSS (Marion)</option><option value="Southampton DSS (Courtland)">Southampton DSS (Courtland)</option><option value="Spotsylvania DSS (Spotsylvania)">Spotsylvania DSS (Spotsylvania)</option><option value="Stafford DSS (Stafford)">Stafford DSS (Stafford)</option><option value="Suffolk DSS (Suffolk)">Suffolk DSS (Suffolk)</option><option value="Surry DSS (Surry)">Surry DSS (Surry)</option><option value="Sussex DSS (Sussex)">Sussex DSS (Sussex)</option><option value="Tazewell DSS (Tazewell)">Tazewell DSS (Tazewell)</option><option value="Virginia Beach DSS (Virginia Beach)">Virginia Beach DSS (Virginia Beach)</option><option value="Warren DSS (Front Royal)">Warren DSS (Front Royal)</option><option value="Washington DSS (Bristol)">Washington DSS (Bristol)</option><option value="Westmoreland DSS (Montross)">Westmoreland DSS (Montross)</option><option value="Williamsburg DSS (Williamsburg)">Williamsburg DSS (Williamsburg)</option><option value="Winchester DSS (Winchester)">Winchester DSS (Winchester)</option><option value="Wise DSS (Wise)">Wise DSS (Wise)</option><option value="Wythe DSS (Wytheville)">Wythe DSS (Wytheville)</option><option value="York-Poquoson DSS (Yorktown)">York-Poquoson DSS (Yorktown)</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">If not listed, list your agency here:</label><input name="CST_5" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client's Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Emergency or Planned Placement?</label><select name="CST_20" class="er_fld_required"><option value="Planned">Planned</option><option value="Emergency">Emergency</option></select></li><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date Placement is Needed:</label><input class="cst_datepicker er_fld_required" name="CST_21" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_FirstName" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name:</label><input name="CST_8" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_MiddleInitial" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Middle Name:</label><input name="CST_9" type="text"></li><li class="er_fld_type_text" draggable="false" map_to="CC_LastName" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name:</label><input name="CST_10" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Race" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Race:</label><select name="CST_13"><option value="- Not Specified -">- Not Specified -</option><option value="African" selected="">African</option><option value="African American">African American</option><option value="Asian">Asian</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Hispanic">Hispanic</option><option value="Latino">Latino</option><option value="Middle Eastern">Middle Eastern</option><option value="Multi-Racial">Multi-Racial</option><option value="Native American">Native American</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;" map_to="CC_Gender"><i class="fa fa-caret-down"></i><label class="er_fld_label">Gender</label><select name="CST_14"><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_date" draggable="false" map_to="CC_DOB" style="width: 20%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth:</label><input class="cst_datepicker" name="CST_12" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 20%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_11" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Part of a Sibling Group?</label><select name="CST_17"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label">If Yes, How Many?</label><input name="CST_18" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please list their siblings and ages here:</label><textarea name="CST_19" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_ReferralReason_Ref" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Reason for Referral:</label><select name="CST_16"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Abandonment">Abandonment</option><option value="CHINS">CHINS</option><option value="Emergency Placement">Emergency Placement</option><option value="Failure to Protect">Failure to Protect</option><option value="Improper Supervision">Improper Supervision</option><option value="Medical Neglect">Medical Neglect</option><option value="Mental Neglect">Mental Neglect</option><option value="Neglect">Neglect</option><option value="Physical Abuse">Physical Abuse</option><option value="Physical Neglect">Physical Neglect</option><option value="Sexual Abuse">Sexual Abuse</option><option value="Step Down to TFC">Step Down to TFC</option><option value="Substance Abuse">Substance Abuse</option><option value="Voluntary">Voluntary</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" map_to="CC_RefSecReason_Ref" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please describe the client's history and needs below:</label><textarea name="CST_15" style="width:100%;" class=""></textarea></li></ul>
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