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_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">                                                      MOUNT MORIAH HOMES - Intake Form
</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Please fill out the Intake Form. Once we have reviewed this submission, our office will get in touch.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Submission</label><input class="cst_datepicker er_fld_required" name="CST_69" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Is this a new file/youth for the Caseworker?</label><select name="CST_59" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="Yes">Yes</option><option value="No">No</option><option value="N/A">N/A</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_FirstName">
<i class="fa fa-font"></i><label class="er_fld_label required">Youth First Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_MiddleInitial">
<i class="fa fa-font"></i><label class="er_fld_label">Youth Middle Name</label><input name="CST_3" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_LastName">
<i class="fa fa-font"></i><label class="er_fld_label required">Youth Last Name</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_6" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Gender">
<i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_5" 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">Child Welfare Status</label><select name="CST_8" class="er_fld_width100"><option value="- Select -">- Select -</option><option value="TGO">TGO</option><option value="PGO">PGO</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">DFNA Agency</label><select name="CST_9" class="er_fld_width100 er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="Akamkisipatinaw Ohpikhawasowin Child and Family Services (AKO)">Akamkisipatinaw Ohpikhawasowin Child and Family Services (AKO)</option><option value="Athabasca Tribal Council Child and Family Services">Athabasca Tribal Council Child and Family Services</option><option value="Bigstone Cree Social Services Society ">Bigstone Cree Social Services Society </option><option value="Blood Tribe Child Protection Services ">Blood Tribe Child Protection Services </option><option value="Kasohkowew Child Wellness Society ">Kasohkowew Child Wellness Society </option><option value="KTC Child and Family Services ">KTC Child and Family Services </option><option value="Lesser Slave Indian Regional Council">Lesser Slave Indian Regional Council</option><option value="Little Red River Cree Nation Mamawi Awasis Society ">Little Red River Cree Nation Mamawi Awasis Society </option><option value="North Peace Tribal Council">North Peace Tribal Council</option><option value="Pikani Child and Family Services ">Pikani Child and Family Services </option><option value="Saddle Lake - Wahkohtowin Society ">Saddle Lake - Wahkohtowin Society </option><option value="Siksika Family Services Corporation">Siksika Family Services Corporation</option><option value="Stoney Nakoda Child and Family Services Society">Stoney Nakoda Child and Family Services Society</option><option value="Sturgeon Lake Child and Family Services">Sturgeon Lake Child and Family Services</option><option value="Sunchild Child and Family Services ">Sunchild Child and Family Services </option><option value="Tribal Chiefs Child and Family Services (East)">Tribal Chiefs Child and Family Services (East)</option><option value="Tribal Chiefs Child and Family Services (West)">Tribal Chiefs Child and Family Services (West)</option><option value="Tsuu T'ina Child and Family Services ">Tsuu T'ina Child and Family Services </option><option value="Western Cree Tribal Council Child, Youth and Family Enhancement ">Western Cree Tribal Council Child, Youth and Family Enhancement </option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_9" er_fld_condvals="er_fld_showif_values=Other">
<i class="fa fa-font"></i><label class="er_fld_label">Other DNFA Agency</label><input name="CST_98" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref">
<i class="fa fa-font"></i><label class="er_fld_label required">Agency Phone Number</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="none">
<i class="fa fa-font"></i><label class="er_fld_label">Agency On-Call Number</label><input name="CST_12" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringWorker_Ref">
<i class="fa fa-font"></i><label class="er_fld_label">Caseworker Name</label><input name="CST_14" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Caseworker Cell</label><input name="CST_17" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Caseworker Email</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Medical 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">Any disabilities?</label><select name="CST_19" class="er_fld_width50"><option value="- Select -" selected="">- Select -</option><option value="N/A">N/A</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_19" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Please identify</label><textarea name="CST_20" style="width:100%;"></textarea></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">Any medical diagnosis?</label><select name="CST_21" class="er_fld_width50"><option value="- Select -" selected="">- Select -</option><option value="N/A">N/A</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_21" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Medical Diagnosis (If applicable)</label><textarea name="CST_22" style="width:100%;"></textarea></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">Does the youth have medication?</label><select name="CST_23"><option value="- Select -" selected="">- Select -</option><option value="N/A">N/A</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_23" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Medication Type</label><textarea name="CST_24" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Youth Education 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">Is the youth willing to attend school?</label><select name="CST_25" class="er_fld_required"><option value="- Select -">- Select -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" map_to="CC_School_Grade" er_fld_condfld="CST_26" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Grade</label><input name="CST_28" type="text" class="er_fld_width100"></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 required">Is the youth currently enrolled in school?</label><select name="CST_26" class="er_fld_required"><option value="- Select -">- Select -</option><option value="Yes">Yes</option><option value="No">No</option><option value="N/A">N/A</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_26" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Program Enrolled Into</label><input name="CST_29" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Youth Behaviours</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown sortable-chosen" draggable="true" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth destroy property on a regular basis?</label><select name="CST_27" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Is the youth physically abusive towards others?</label><select name="CST_30" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_70" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_71" 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 required">Does the youth have a history of suicide attempts?</label><select name="CST_31" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the resident of a history of self-harm?</label><select name="CST_32" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_72" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_73" 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 required">Is the youth a cutter?</label><select name="CST_33" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a history of stealing?</label><select name="CST_34" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_74" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_75" 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 required">Does the youth have a history of depression?</label><select name="CST_35" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a history of substance abuse?</label><select name="CST_36" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_76" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_77" 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 required">Does the youth have a history of drug abuse?</label><select name="CST_37" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth suffer from low self-esteem?</label><select name="CST_38" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_78" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_79" type="text"></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">Are there family problems related to grief, separation and loss?</label><select name="CST_39" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth display manipulative or attention seeking behavior?</label><select name="CST_41" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_80" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_81" 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 required">Does the youth respect personal boundaries?</label><select name="CST_40" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Is the youth easily influenced?</label><select name="CST_53" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_82" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_83" type="text"></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">Does the youth have a history of violent behavior?</label><select name="CST_42" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a history of physical abuse?</label><select name="CST_43" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_84" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_86" 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 required">Does the youth have a history of sexual abuse?</label><select name="CST_44" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a history of emotional abuse?</label><select name="CST_45" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_87" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_88" 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 required">Does the youth have a history of school problems?</label><select name="CST_46" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth exhibit inappropriate sexual behaviors?</label><select name="CST_47" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_89" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_90" 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 required">Does the youth have a history of defiance towards authority?</label><select name="CST_48" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have a history of AWOL?</label><select name="CST_54" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></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">Notes</label><input name="CST_96" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_97" 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 required">Does the youth have any eating disorders?</label><select name="CST_49" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth need help with self-care?</label><select name="CST_50" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_91" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_92" 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 required">Does the youth have any specific safety needs?</label><select name="CST_51" class="er_fld_required"><option value="- Select -" selected="">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth have social media safety issues?</label><select name="CST_52" class="er_fld_required"><option value="- Select -">- Select -</option><option value="No Issue (0)">No Issue (0)</option><option value="Minor (1)">Minor (1)</option><option value="Moderate (2)">Moderate (2)</option><option value="Severe (3)">Severe (3)</option><option value="Unknown ">Unknown </option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_93" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label">Notes</label><input name="CST_94" type="text"></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">Does the youth have any specific recreational needs?</label><select name="CST_55" class="er_fld_required"><option value="- Select -">- Select -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Somewhat">Somewhat</option><option value="Unknown ">Unknown </option><option value="N/A">N/A</option></select></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">Notes</label><input name="CST_95" 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>Youth and SIL</label><hr></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 required">Has the youth been in SIL previously?</label><select name="CST_65" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Does the youth know what a SIL program is?</label><select name="CST_66" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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 required">Does the youth know about the potential move?</label><select name="CST_64" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Is the youth willing to go to school, volunteer and/or work?</label><select name="CST_67" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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">Other Comments </label><textarea name="CST_61" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Thank you for your submission. </div></li></ul>