Online Referral
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<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_noprint"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Requested Services / Campos Personalizados</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="Behavioral Health Services (counseling, skills training and/or wraparound) / Servicios de salud conductual (asesoramiento, entrenamiento de habilidades, y/o servicios integrales)">Behavioral Health Services (counseling, skills training and/or wraparound) / Servicios de salud conductual (asesoramiento, entrenamiento de habilidades, y/o servicios integrales)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="CANS 2.0 (eCANS) - Only initial & annual assessment / CANS 2.0 (eCANS) - Sólo evaluación inicial y anual">CANS 2.0 (eCANS) - Only initial & annual assessment / CANS 2.0 (eCANS) - Sólo evaluación inicial y anual</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_22" value="Psychiatric Services (medication management with a doctor) / Servicios psiquiátricos (gestión de medicamentos con un médico)">Psychiatric Services (medication management with a doctor) / Servicios psiquiátricos (gestión de medicamentos con un médico)</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_22" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_22_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">Please complete/submit the form below. Por favor, llene y envíe el siguiente formulario. If you have any questions regarding Mosaic's services or any of the eligibility criteria listed below, please email referrals@mosaic-consult.com or call (800) 427-6144. Si tiene alguna pregunta sobre los servicios de Mosaic o cualquiera de los criterios de elegibilidad que se enumeran a continuación, envíe un correo electrónico a referrals@mosaic-consult.com o llame al (800) 427-6144. Note: When requesting multiple services, please expect to be contacted multiple times to schedule appointments with multiple providers. Nota: Cuando solicite múltiples servicios, espere que lo contacten varias veces para programar citas con múltiples proveedores.</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_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">ELIGIBILITY CRITERIA: An individual is eligible for Mosaic services if the individual is: · age 3 and older; · a resident of the State of Texas; · enrolled in a managed care Medicaid program or has insurance with one of our contracted insurance companies; and · a child or adolescent with a serious emotional disturbance with a DSM-V primary diagnosis or has experienced a severe traumatic event (e.g. abuse/neglect, home removal, etc.). · only children or young adults below the age of 20 may receive counseling services (this does not pertain to psychiatry, skills training and/or wraparound). </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_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">* = required fields / * = campos obligatorios</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_22" er_fld_condvals="er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">ELIGIBILITY CRITERIA: / CRITERIOS DE ELEGIBILIDAD: An individual is eligible for Mosaic Psychiatry services if the individual is: Una persona es elegible para los servicios de Mosaic Psychiatry si: · age 5 and older; tiene 5 años de edad o más; · a resident of the State of Texas; es residente del Estado de Texas; · enrolled in a managed care Medicaid program or has insurance with one of our contracted insurance companies; and está inscrito en un programa de atención administrada de Medicaid o tiene un seguro con una de nuestras compañías de seguros contratadas; y · a child or adolescent with a serious emotional disturbance with a DSM-V primary diagnosis or has experienced a severe traumatic event (e.g. abuse/neglect, home removal, etc.). es un niño o adolescente con un trastorno emocional grave con un diagnóstico primario de DSM-V o ha sufrido un evento traumático grave (por ejemplo, abuso/descuido, expulsión del hogar, etc.). </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-header"></i><label>Client Information / Información del cliente</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" map_to="CC_Name_First" style="width: 20%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's First Name / Primero nombre del cliente</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_Name_Middle" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label">Client's Middle Name / Segundo nombre del cliente </label><input name="CST_2" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_Name_Last" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's Last Name / Apellido del cliente</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label">Client's Nickname / Apodo del cliente</label><input name="CST_4" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" map_to="CC_Gender" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client's Gender / Sexo del cliente</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Female / Femenino">Female / Femenino</label><label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Male /Masculino">Male /Masculino</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_5" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_5_Other" type="text"></label></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_DOB" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-calendar"></i><label class="er_fld_label required">Client's DOB / Fecha de nacimiento del cliente</label><input class="cst_datepicker er_fld_required er_fld_width75" name="CST_6" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" map_to="CC_SSN" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's SSN (Enter 000-00-0000 if unknown at time of referral) / Número de seguro social del cliente (Introduzca 000-00- 0000 si se desconoce al momento de la remisión) </label><input name="CST_7" type="text" class="er_fld_required er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" map_to="CC_Address_Street_1" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's Street Address / Dirección del cliente </label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Address_City" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's City / Ciudad del cliente </label><input name="CST_10" 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: 25%;" map_to="CC_Address_State" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client's State / Estado del cliente</label><input name="CST_11" type="text" value="Texas" class="er_fld_required er_fld_width50"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Address_Zip" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-hashtag"></i><label class="er_fld_label required">Client's ZIP Code / Código postal del cliente</label><input name="CST_12" type="text" class="er_fld_required er_fld_width50"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" map_to="CC_Address_County" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Client's County / Condado del cliente</label><select name="CST_13" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Anderson">Anderson</option><option value="Andrews">Andrews</option><option value="Angelina">Angelina</option><option value="Aransas">Aransas</option><option value="Archer">Archer</option><option value="Armstrong">Armstrong</option><option value="Atascosa">Atascosa</option><option value="Austin">Austin</option><option value="Bailey">Bailey</option><option value="Bandera">Bandera</option><option value="Bastrop ">Bastrop </option><option value="Baylor">Baylor</option><option value="Bee">Bee</option><option value="Bell">Bell</option><option value="Bexar">Bexar</option><option value="Blanco">Blanco</option><option value="Borden">Borden</option><option value="Bosque">Bosque</option><option value="Bowie">Bowie</option><option value="Brazoria">Brazoria</option><option value="Brazos">Brazos</option><option value="Brewster">Brewster</option><option value="Briscoe">Briscoe</option><option value="Brooks">Brooks</option><option value="Brown">Brown</option><option value="Burleson">Burleson</option><option value="Burnet">Burnet</option><option value="Caldwell">Caldwell</option><option value="Calhoun">Calhoun</option><option value="Callahan">Callahan</option><option value="Cameron">Cameron</option><option value="Camp">Camp</option><option value="Carson">Carson</option><option value="Cass">Cass</option><option value="Castro">Castro</option><option value="Chambers">Chambers</option><option value="Cherokee">Cherokee</option><option value="Childress">Childress</option><option value="Clay">Clay</option><option value="Cochran">Cochran</option><option value="Coke">Coke</option><option value="Coleman">Coleman</option><option value="Collin">Collin</option><option value="Collingsworth">Collingsworth</option><option value="Colorado">Colorado</option><option value="Comal">Comal</option><option value="Comanche">Comanche</option><option value="Concho">Concho</option><option value="Cooke">Cooke</option><option value="Coryell">Coryell</option><option value="Cottle">Cottle</option><option value="Crane">Crane</option><option value="Crockett">Crockett</option><option value="Crosby">Crosby</option><option value="Culberson">Culberson</option><option value="Dallam">Dallam</option><option value="Dallas">Dallas</option><option value="Dawson">Dawson</option><option value="De Witt">De Witt</option><option value="Deaf Smith">Deaf Smith</option><option value="Delta">Delta</option><option value="Denton">Denton</option><option value="Dickens">Dickens</option><option value="Dimmit">Dimmit</option><option value="Donley">Donley</option><option value="Duval">Duval</option><option value="Eastland">Eastland</option><option value="Ector">Ector</option><option value="Edwards">Edwards</option><option value="El Paso">El Paso</option><option value="Ellis">Ellis</option><option value="Erath">Erath</option><option value="Falls">Falls</option><option value="Fannin">Fannin</option><option value="Fayette">Fayette</option><option value="Fisher">Fisher</option><option value="Floyd">Floyd</option><option value="Foard">Foard</option><option value="Fort Bend">Fort Bend</option><option value="Franklin">Franklin</option><option value="Freestone">Freestone</option><option value="Frio">Frio</option><option value="Gaines">Gaines</option><option value="Galveston">Galveston</option><option value="Garza">Garza</option><option value="Gillespie">Gillespie</option><option value="Glasscock">Glasscock</option><option value="Goliad">Goliad</option><option value="Gonzales">Gonzales</option><option value="Gray">Gray</option><option value="Grayson">Grayson</option><option value="Gregg">Gregg</option><option value="Grimes">Grimes</option><option value="Guadalupe">Guadalupe</option><option value="Hale">Hale</option><option value="Hall">Hall</option><option value="Hamilton">Hamilton</option><option value="Hansford">Hansford</option><option value="Hardeman">Hardeman</option><option value="Hardin">Hardin</option><option value="Harris">Harris</option><option value="Harrison">Harrison</option><option value="Hartley">Hartley</option><option value="Haskell">Haskell</option><option value="Hays">Hays</option><option value="Hemphill">Hemphill</option><option value="Henderson">Henderson</option><option value="Hidalgo">Hidalgo</option><option value="Hill">Hill</option><option value="Hockley">Hockley</option><option value="Hood">Hood</option><option value="Hopkins">Hopkins</option><option value="Houston">Houston</option><option value="Howard">Howard</option><option value="Hudspeth">Hudspeth</option><option value="Hunt">Hunt</option><option value="Hutchinson">Hutchinson</option><option value="Irion">Irion</option><option value="Jack">Jack</option><option value="Jackson">Jackson</option><option value="Jasper">Jasper</option><option value="Jeff Davis">Jeff Davis</option><option value="Jefferson">Jefferson</option><option value="Jim Hogg">Jim Hogg</option><option value="Jim Wells">Jim Wells</option><option value="Johnson">Johnson</option><option value="Jones">Jones</option><option value="Karnes">Karnes</option><option value="Kaufman">Kaufman</option><option value="Kendall">Kendall</option><option value="Kenedy">Kenedy</option><option value="Kent">Kent</option><option value="Kerr ">Kerr </option><option value="Kimble">Kimble</option><option value="King">King</option><option value="Kinney">Kinney</option><option value="Kleberg">Kleberg</option><option value="Knox">Knox</option><option value="La Salle">La Salle</option><option value="Lamar">Lamar</option><option value="Lamb">Lamb</option><option value="Lampasas">Lampasas</option><option value="Lavaca">Lavaca</option><option value="Lee">Lee</option><option value="Leon">Leon</option><option value="Liberty">Liberty</option><option value="Limestone">Limestone</option><option value="Lipscomb">Lipscomb</option><option value="Live Oak">Live Oak</option><option value="Llano">Llano</option><option value="Loving">Loving</option><option value="Lubbock">Lubbock</option><option value="Lynn">Lynn</option><option value="Madison">Madison</option><option value="Marion">Marion</option><option value="Martin">Martin</option><option value="Mason">Mason</option><option value="Matagorda">Matagorda</option><option value="Maverick">Maverick</option><option value="McCulloch">McCulloch</option><option value="McLennan">McLennan</option><option value="McMullen">McMullen</option><option value="Medina">Medina</option><option value="Menard">Menard</option><option value="Midland">Midland</option><option value="Milam">Milam</option><option value="Mills">Mills</option><option value="Mitchell">Mitchell</option><option value="Montague">Montague</option><option value="Montgomery">Montgomery</option><option value="Moore">Moore</option><option value="Morris">Morris</option><option value="Motley">Motley</option><option value="Nacogdoches">Nacogdoches</option><option value="Navarro">Navarro</option><option value="Newton">Newton</option><option value="Nolan">Nolan</option><option value="Nueces">Nueces</option><option value="Ochiltree">Ochiltree</option><option value="Oldham">Oldham</option><option value="Orange">Orange</option><option value="Palo Pinto">Palo Pinto</option><option value="Panola">Panola</option><option value="Parker ">Parker </option><option value="Parmer">Parmer</option><option value="Pecos">Pecos</option><option value="Polk">Polk</option><option value="Potter">Potter</option><option value="Presidio">Presidio</option><option value="Rains">Rains</option><option value="Randall">Randall</option><option value="Reagan">Reagan</option><option value="Real">Real</option><option value="Red River">Red River</option><option value="Reeves">Reeves</option><option value="Refugio">Refugio</option><option value="Roberts">Roberts</option><option value="Robertson">Robertson</option><option value="Rockwall">Rockwall</option><option value="Runnels">Runnels</option><option value="Rusk">Rusk</option><option value="Sabine">Sabine</option><option value="San Augustine">San Augustine</option><option value="San Jacinto">San Jacinto</option><option value="San Patricio">San Patricio</option><option value="San Saba">San Saba</option><option value="Schleicher">Schleicher</option><option value="Scurry">Scurry</option><option value="Shackelford">Shackelford</option><option value="Shelby">Shelby</option><option value="Sherman">Sherman</option><option value="Smith">Smith</option><option value="Somervell">Somervell</option><option value="Starr">Starr</option><option value="Stephens">Stephens</option><option value="Sterling">Sterling</option><option value="Stonewall">Stonewall</option><option value="Sutton">Sutton</option><option value="Swisher">Swisher</option><option value="Tarrant">Tarrant</option><option value="Taylor">Taylor</option><option value="Terrell">Terrell</option><option value="Terry">Terry</option><option value="Throckmorton">Throckmorton</option><option value="Titus">Titus</option><option value="Tom Green">Tom Green</option><option value="Travis">Travis</option><option value="Trinity">Trinity</option><option value="Tyler">Tyler</option><option value="Upshur">Upshur</option><option value="Upton">Upton</option><option value="Uvalde">Uvalde</option><option value="Val Verde">Val Verde</option><option value="Van Zandt">Van Zandt</option><option value="Victoria">Victoria</option><option value="Walker">Walker</option><option value="Waller">Waller</option><option value="Ward">Ward</option><option value="Washington">Washington</option><option value="Webb">Webb</option><option value="Wharton ">Wharton </option><option value="Wheeler">Wheeler</option><option value="Wichita">Wichita</option><option value="Wilbarger">Wilbarger</option><option value="Willacy">Willacy</option><option value="Williamson">Williamson</option><option value="Wilson">Wilson</option><option value="Winkler">Winkler</option><option value="Wise">Wise</option><option value="Wood">Wood</option><option value="Yoakum">Yoakum</option><option value="Young">Young</option><option value="Zapata">Zapata</option><option value="Zavala">Zavala</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Race" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Client's Race / Raza del cliente</label><select name="CST_14" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="American Indian or Alaska Native / Indio americano or nativo de Alaska">American Indian or Alaska Native / Indio americano or nativo de Alaska</option><option value="Asian (non-Pacific Islander) / Asiático (isleño no pacífico)">Asian (non-Pacific Islander) / Asiático (isleño no pacífico)</option><option value="Black or African American / Negro o afroamericano">Black or African American / Negro o afroamericano</option><option value="Hispanic or Latino / Hispano o latino">Hispanic or Latino / Hispano o latino</option><option value="Native Hawaiian or Other Pacific Islander / Nativo hawaiano u otro isleño del Pacífico">Native Hawaiian or Other Pacific Islander / Nativo hawaiano u otro isleño del Pacífico</option><option value="White/Caucasian (non-Hispanic/Latino) / Blanco / Caucásico (No hispano/latino)">White/Caucasian (non-Hispanic/Latino) / Blanco / Caucásico (No hispano/latino)</option><option value="Multiple Races / Multirracial">Multiple Races / Multirracial</option></select></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Religion" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Client's Religion / Religión del cliente</label><select name="CST_15" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Christian (Catholic) / Católico">Christian (Catholic) / Católico</option><option value="Christian (Not Specified) / Cristiano (no especificado)">Christian (Not Specified) / Cristiano (no especificado)</option><option value="Christian (Protestant) / Cristiano (protestante)">Christian (Protestant) / Cristiano (protestante)</option><option value="Jewish / Judío">Jewish / Judío</option><option value="Muslim / Musulmán">Muslim / Musulmán</option><option value="Non-religious / No religioso">Non-religious / No religioso</option><option value="Other / Otra">Other / Otra</option></select></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Language" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Client's Primary Language / Idioma principal del cliente</label><select name="CST_16" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="American Sign Language ">American Sign Language </option><option value="Arabic">Arabic</option><option value="Bengali">Bengali</option><option value="Cambodian (Khmer)">Cambodian (Khmer)</option><option value="Cantonese">Cantonese</option><option value="Chinese">Chinese</option><option value="English / Inglés">English / Inglés</option><option value="French">French</option><option value="German">German</option><option value="Hebrew">Hebrew</option><option value="Hindi">Hindi</option><option value="Italian">Italian</option><option value="Japanese">Japanese</option><option value="Javanese">Javanese</option><option value="Korean">Korean</option><option value="Mandarin">Mandarin</option><option value="Marathi">Marathi</option><option value="Nepali">Nepali</option><option value="Polish">Polish</option><option value="Portuguese">Portuguese</option><option value="Punjabi">Punjabi</option><option value="Russian">Russian</option><option value="Spanish / Español">Spanish / Español</option><option value="Tagalog">Tagalog</option><option value="Tamil">Tamil</option><option value="Telugu">Telugu</option><option value="Turkish">Turkish</option><option value="Tigrinya">Tigrinya</option><option value="Urdu">Urdu</option><option value="Vietnamese">Vietnamese</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client's Weight / Peso del cliente</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_73" value="I will provide the Weight in pounds / Le proporcionaré el Peso en libras">I will provide the Weight in pounds / Le proporcionaré el Peso en libras</label><label class="er_option"><input class="type_radio" type="radio" name="CST_73" value="I will provide the weight during the first appointment with the doctor. / Le proporcionaré el peso durante la primera cita con el médico.">I will provide the weight during the first appointment with the doctor. / Le proporcionaré el peso durante la primera cita con el médico.</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_73" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_73_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_73" er_fld_condvals="er_fld_showif_values=I+will+provide+the+Weight+in+pounds+%2F++Le+proporcionar%C3%A9+el+Peso+en+libras"> <i class="fa fa-font"></i><label class="er_fld_label required">Weight in pounds / Peso en libras</label><input name="CST_75" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 25%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client's Height / Altura del cliente</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="I will provide the Height in inches / Le proporcionaré la altura en pulgadas">I will provide the Height in inches / Le proporcionaré la altura en pulgadas</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="I will provide the height during the first appointment with the doctor. / Le proporcionaré la altura durante la primera cita con el médico. ">I will provide the height during the first appointment with the doctor. / Le proporcionaré la altura durante la primera cita con el médico. </label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_76" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_76_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif er_fld_selected" draggable="false" style="width: 25%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=I+will+provide+the+Height+in+inches+%2F++Le+proporcionar%C3%A9+la+altura+en+pulgadas"> <i class="fa fa-font"></i><label class="er_fld_label required">Height in inches / altura en pulgadas</label><input name="CST_77" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" map_to="CC_Education" style="width: 33.3333%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual" er_fld_condfld="CST_22"><i class="fa fa-caret-down"></i><label class="er_fld_label">Client's Grade or Education Level / Grado o nivel educativo del cliente</label><select name="CST_17" class="er_fld_width75 er_fld_blank"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown / Grado desconocido">Unknown / Grado desconocido</option><option value="Pre-School / Preescolar">Pre-School / Preescolar</option><option value="Kindergarten / El kinder">Kindergarten / El kinder</option><option value="1st Grade">1st Grade</option><option value="2nd Grade">2nd Grade</option><option value="3rd Grade">3rd Grade</option><option value="4th Grade">4th Grade</option><option value="5th Grade">5th Grade</option><option value="6th Grade">6th Grade</option><option value="7th Grade">7th Grade</option><option value="8th Grade">8th Grade</option><option value="9th Grade">9th Grade</option><option value="10th Grade">10th Grade</option><option value="11th Grade">11th Grade</option><option value="12th Grade">12th Grade</option><option value="College / El colegio">College / El colegio</option><option value="Vocational Program / programa vocacional">Vocational Program / programa vocacional</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's School Name / Nombre de la escuela del cliente</label><input name="CST_18" type="text" class="er_fld_blank er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's School District (Enter N/A if client is not school aged) / Distrito escolar del cliente (ingrese N/A si el cliente no tiene edad escolar) </label><input name="CST_71" type="text" class="er_fld_required er_fld_blank"></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_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-font"></i><label class="er_fld_label">DFPS Caseworker Name / Nombre del trabajador social del DFPS</label><input name="CST_66" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-font"></i><label class="er_fld_label">DFPS Caseworker Email / Correo electrónico del trabajador social del DFPS</label><input name="CST_67" type="text" class="er_fld_blank"></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_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-font"></i><label class="er_fld_label">DFPS Caseworker Phone Number / Número de teléfono del trabajador social del DFPS</label><input name="CST_68" type="text" class="er_fld_blank"></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"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-header"></i><label>Client's Insurance Information / Información sobre el seguro del cliente</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" map_to="Nothing" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Type of Insurance Coverage / Tipo de cobertura del seguro</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_19" value="Wellpoint">Wellpoint</label><label class="er_option"><input class="type_radio" type="radio" name="CST_19" value="Community First">Community First</label><label class="er_option"><input class="type_radio" type="radio" name="CST_19" value="Superior Health">Superior Health</label><label class="er_option"><input class="type_radio" type="radio" name="CST_19" value="TMHP">TMHP</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_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Type of Insurance Coverage (CANS 2.0)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_56" value="Superior Foster Care" checked="">Superior Foster Care</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_56" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_56_Other" type="text"></label></li><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">CANS 2.0 is covered only by Superior Foster Care insurance.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22" map_to="CC_Medicaid"> <i class="fa fa-font"></i><label class="er_fld_label required">Client's Medicaid No. (If no Medicaid # please enter 00000000) / No. de Medicaid del cliente (Si no hay # de Medicaid, introduzca 000000000):</label><input name="CST_59" type="text" class="er_fld_required"></li><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Service Location Preference (if available) / Preferencia de ubicación del servicio (si disponible)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_60" value="In the Office / En la oficina">In the Office / En la oficina</label><label class="er_option"><input class="type_radio" type="radio" name="CST_60" value="Virtual/Telehealth">Virtual/Telehealth</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_60" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_60_Other" type="text"></label></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=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual" er_fld_condfld="CST_22"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Service Location Preference (if available)</label> <label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_21" value="Client's Home">Client's Home</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_21" value="In the Office">In the Office</label><label class="er_option"><input class="type_radio er_fld_required er_fld_blank" type="radio" name="CST_21" value="Virtual/Telehealth">Virtual/Telehealth</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_21" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_21_Other" type="text"></label></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"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-header"></i><label>Reason for Referral / Area of Need / Motivo de la remisión/Área de necesidad</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are the requested services Court Ordered? / ¿Los servicios solicitados son por Orden Judicial? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_23" 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_23" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_23_Other" type="text"></label></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 required">Which services are Court Ordered? / ¿Cuáles son los servicios que han sido ordenados por el tribunal?</label><textarea name="CST_24" style="width:100%;" class="er_fld_required"></textarea></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_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"> <i class="fa fa-font"></i><label class="er_fld_label">Permanency Goal / Objetivo de permanencia </label><input name="CST_25" type="text" class="er_fld_blank"></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_22" er_fld_condvals="er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Reason for Referral: / Razón de la remisión:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_62" value="Psychiatry (initial assessment for medication and/or medication management services) / Psiquiatría y (evaluación inicial de medicación y/o servicios de gestión de medicamentos)" checked="">Psychiatry (initial assessment for medication and/or medication management services) / Psiquiatría y (evaluación inicial de medicación y/o servicios de gestión de medicamentos)</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_62" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_62_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Area of Need? / ¿Área de necesidad?</label><textarea name="CST_65" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-paragraph"></i><label class="er_fld_label required">Reason for Referral or Area of Need?</label><textarea name="CST_26" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Diagnosis (if known) / Diagnóstico principal (si se sabe)</label><textarea name="CST_69" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Primary Diagnosis</label><textarea name="CST_27" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Risk Factors / Presenting Problems / Factores de riesgo/Problemas que presenta</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Self Harm / Autolesión">Self Harm / Autolesión</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Harm to Others / Daño a otros">Harm to Others / Daño a otros</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Bullying Behaviors / Comportamientos de acoso escolar">Bullying Behaviors / Comportamientos de acoso escolar</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Runaway / Huida">Runaway / Huida</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Delinquency / Delincuencia">Delinquency / Delincuencia</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Fire Setting / Provocar incendios">Fire Setting / Provocar incendios</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Violence / Violencia">Violence / Violencia</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Sexual Aggression / Agresión sexual">Sexual Aggression / Agresión sexual</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="N/A">N/A</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_28" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_28_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Summary of Risk Factors/Presenting Problems: Resumen de los factores de riesgo/Problemas que se presentan:</label><textarea name="CST_29" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Severe Emotional, Behavioral, or Mental Health Needs: / Necesidades Emocionales, Conductuales o de Salud Mental graves:</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Psychosis / Psicosis">Psychosis / Psicosis</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Mania / Manía">Mania / Manía</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Impulsivity/Hyperactivity / Impulsividad/hiperactividad">Impulsivity/Hyperactivity / Impulsividad/hiperactividad</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Depression / Depresión">Depression / Depresión</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Anxiety / Ansiedad">Anxiety / Ansiedad</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Oppositional / Opositivo">Oppositional / Opositivo</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Anger / Ira">Anger / Ira</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Substance Use / Consumo de sustancias">Substance Use / Consumo de sustancias</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Eating Disturbance / Alteración de la alimentación">Eating Disturbance / Alteración de la alimentación</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Autism Spectrum Disorder / Trastorno del espectro autista">Autism Spectrum Disorder / Trastorno del espectro autista</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_55" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_55_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condvals="er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual" er_fld_condfld="CST_22"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">DFPS PID # / </label><input name="CST_8" type="text" class="er_fld_width100 er_fld_required er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual"><i class="fa fa-calendar"></i><label class="er_fld_label required">Please provide the removal date from home (Removal date is required for all CANS 2.0 referrals)</label><input class="cst_datepicker er_fld_width50 er_fld_required" name="CST_42" type="text"></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: 33.3333%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does Client already have a therapist? / ¿El Cliente cuenta ya con un terapeuta? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_31" value="Unknown / Desconocido">Unknown / Desconocido</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_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">What is the therapist's name? / ¿Cuál es el nombre del terapeuta? </label><input name="CST_32" type="text" class="er_fld_width100 er_fld_blank"></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"></div></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: 33.3333%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Currently on Medications? / ¿Actualmente toma medicamentos?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_35" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_35" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_35" value="Unknown / Desconocido">Unknown / Desconocido</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_35" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_35_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_medium er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_35" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please indicate medication name, dosage and frequency / Por favor, indique el nombre del medicamento, la dosis y frecuencia </label><textarea name="CST_36" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col4" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the child or youth experienced psychiatric hospitalization in the past 90 days? / ¿El niño o joven ha sido hospitalizado por razones psiquiátricas en los últimos 90 días?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_51" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_51" 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_51" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_51_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the Child or Youth experienced any crisis episodes in the past 90 days? / ¿Ha tenido el niño o joven algún episodio de crisis en los últimos 90 días?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_52" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_52" 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_52" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_52_Other" type="text"></label></li><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">Examples include (but are not limited to): Emergency room visits, 23-hour observation periods, need for mobile crisis response, emergency respite, etc. Los ejemplos incluyen (pero no se limitan a): Visitas a la sala de emergencias, periodos de observación de 23 horas, necesidad de respuesta móvil a la crisis, respiro de emergencia, etc. </div></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_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has the Child or Youth had any involvement with Juvenile Justice in the past 30 days? / ¿Ha tenido el niño o el joven alguna intervención de la justicia de menores en los últimos 30 días?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_53" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_53" 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_53" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_53_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-header"></i><label>Caregiver/Parent/Legal Guardian Information / Información sobre el cuidador/padre/tutor legal </label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="Nothing" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">First & Last Name of Caregiver/Parent/Legal Guardian / Nombre y apellido del cuidador/padre/tutor legal </label><input name="CST_37" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22" map_to="Nothing"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Caregiver's Relationship to Client / Relación del cuidador con el cliente</label><select name="CST_38" class="er_fld_required"><option value="- Not Specified - " selected="">- Not Specified - </option><option value="Foster Parent / Padre temporal">Foster Parent / Padre temporal</option><option value="Kinship Parent / Padre de parentesco">Kinship Parent / Padre de parentesco</option><option value="Adoptive Parent / Padre adoptivo">Adoptive Parent / Padre adoptivo</option><option value="Biological Parent / Padre biológico">Biological Parent / Padre biológico</option><option value="Step-parent / Padrastro">Step-parent / Padrastro</option><option value="Residential Facility / Instalación residencial">Residential Facility / Instalación residencial</option><option value="Self/Adult Client / Usted mismo/Cliente adulto">Self/Adult Client / Usted mismo/Cliente adulto</option><option value="DFPS Caseworker / Trabajador social de DFPS">DFPS Caseworker / Trabajador social de DFPS</option><option value="Unknown / Desconocido">Unknown / Desconocido</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Phone_Mobile" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client/Caregiver mobile # / No. de teléfono de contacto del cuidador</label><input name="CST_39" type="text" class="er_fld_width75 er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Client/Caregiver Best Contact Email / Correo electrónico de contacto del cuidador </label><input name="CST_40" type="text" class="er_fld_required er_fld_width100"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Client/Caregiver Primary Language / Idioma principal del cuidador </label><select name="CST_48" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="American Sign Language">American Sign Language</option><option value="Arabic">Arabic</option><option value="Bengali">Bengali</option><option value="Cambodian (Khmer)">Cambodian (Khmer)</option><option value="Cantonese">Cantonese</option><option value="Chinese">Chinese</option><option value="English">English</option><option value="French">French</option><option value="German">German</option><option value="Hebrew">Hebrew</option><option value="Hindi">Hindi</option><option value="Italian">Italian</option><option value="Japanese">Japanese</option><option value="Javanese">Javanese</option><option value="Korean">Korean</option><option value="Mandarin">Mandarin</option><option value="Marathi">Marathi</option><option value="Nepali">Nepali</option><option value="Polish">Polish</option><option value="Portuguese">Portuguese</option><option value="Punjabi">Punjabi</option><option value="Russian">Russian</option><option value="Spanish">Spanish</option><option value="Tagalog">Tagalog</option><option value="Tamil">Tamil</option><option value="Telugu">Telugu</option><option value="Turkish">Turkish</option><option value="Tigrinya">Tigrinya</option><option value="Urdu">Urdu</option><option value="Vietnamese">Vietnamese</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client's Placement Type / Tipo de colocación del Cliente </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="Foster Home / Hogar de Acogida">Foster Home / Hogar de Acogida</label><label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="Residential Facility / Centro institucional">Residential Facility / Centro institucional</label><label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="Biological Home / Hogar biológico">Biological Home / Hogar biológico</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_41" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_41_Other" type="text"></label></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"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-header"></i><label>Referral Source Information / Información sobre la fuente de remisión</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_ReferringWorker_Ref" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">First & Last Name of Person Making Referral / Nombre y apellido de la persona que hace la remisión </label><input name="CST_43" type="text" class="er_fld_required er_fld_width75"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_ReferralSource_Ref" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual" er_fld_condfld="CST_22"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Referral Source / Fuente de la remisión </label><select name="CST_44" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Pathways - 3H">Pathways - 3H</option><option value="Pathways - CPA">Pathways - CPA</option><option value="Pathways - HAB">Pathways - HAB</option><option value="Pathways - Kinship">Pathways - Kinship</option><option value="Pathways - Psychiatry">Pathways - Psychiatry</option><option value="Self/Parent-Guardian/Family Member">Self/Parent-Guardian/Family Member</option><option value="Turning Point">Turning Point</option><option value="DFPS">DFPS</option><option value="2INgage">2INgage</option><option value="Our Community Our Kids">Our Community Our Kids</option><option value="Saint Francis Ministries">Saint Francis Ministries</option><option value="A World for Children">A World for Children</option><option value="Agape Manor Home">Agape Manor Home</option><option value="Amazing Grace Child & Family Services">Amazing Grace Child & Family Services</option><option value="Angelheart">Angelheart</option><option value="Angel's Crossing">Angel's Crossing</option><option value="Arrow Child & Family Ministries">Arrow Child & Family Ministries</option><option value="Ascension Child and Family Services">Ascension Child and Family Services</option><option value="Athletes for Change">Athletes for Change</option><option value="Benchmark Family Services">Benchmark Family Services</option><option value="Brookhaven Youth Ranch">Brookhaven Youth Ranch</option><option value="Buckner Baptist Children's Home">Buckner Baptist Children's Home</option><option value="Carousel Pediatrics">Carousel Pediatrics</option><option value="Circle of Living Hope">Circle of Living Hope</option><option value="Dallas I.S.D.">Dallas I.S.D.</option><option value="DePelchin">DePelchin</option><option value="Divinity Family Services">Divinity Family Services</option><option value="EMPOWER Priority Grant">EMPOWER Priority Grant</option><option value="EMPOWER Regular Referral">EMPOWER Regular Referral</option><option value="Guardian's Promise, LLC.">Guardian's Promise, LLC.</option><option value="Harmony Family Services">Harmony Family Services</option><option value="HCYR - Ingram Campus">HCYR - Ingram Campus</option><option value="HCYR - Leakey Campus">HCYR - Leakey Campus</option><option value="Jonathan's Place">Jonathan's Place</option><option value="JDC-Taylor County">JDC-Taylor County</option><option value="JDC-Jones County">JDC-Jones County</option><option value="JDC-Throckmorton Count">JDC-Throckmorton Count</option><option value="Kids First, Inc.">Kids First, Inc.</option><option value="Methodist Children's Home Family Outreach">Methodist Children's Home Family Outreach</option><option value="MiOWN HOME">MiOWN HOME</option><option value="New Horizons">New Horizons</option><option value="Open Hearts Open Arms">Open Hearts Open Arms</option><option value="PTFFC">PTFFC</option><option value="Rees-Jones Center">Rees-Jones Center</option><option value="Safe Haven">Safe Haven</option><option value="SAMMinistries">SAMMinistries</option><option value="St. Jude's Ranch for Children">St. Jude's Ranch for Children</option><option value="Superior">Superior</option><option value="The Bair Foundation">The Bair Foundation</option><option value="The Children's Assessment Center">The Children's Assessment Center</option><option value="The Children's Shelter">The Children's Shelter</option><option value="Therapeutic Family Life">Therapeutic Family Life</option><option value="Trulight 127 Ministries">Trulight 127 Ministries</option><option value="Upbring">Upbring</option><option value="Youth in View">Youth in View</option><option value="Other Agency - Not Identified">Other Agency - Not Identified</option></select></li><li class="er_fld_type_dropdown er_fld_showif sortable-chosen" draggable="true" style="width: 20%;" er_fld_condfld="CST_22" er_fld_condvals="er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Referral Source / Fuente de la remisión </label><select name="CST_63" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="EMR Bear Import">EMR Bear Import</option><option value="3H Youth Ranch">3H Youth Ranch</option><option value="Abilene CPA Pathways">Abilene CPA Pathways</option><option value="Abilene Outside CPA">Abilene Outside CPA</option><option value="Abilene Pathways Clinic">Abilene Pathways Clinic</option><option value="Austin Central ">Austin Central </option><option value="Austin CPA Pathways">Austin CPA Pathways</option><option value="Austin Outside CPA">Austin Outside CPA</option><option value="Blue Skies">Blue Skies</option><option value="Bridge to Hope">Bridge to Hope</option><option value="Brookhaven Youth Ranch Austin">Brookhaven Youth Ranch Austin</option><option value="Calabri Health Dallas">Calabri Health Dallas</option><option value="Dallas">Dallas</option><option value="Dallas CPA Pathways">Dallas CPA Pathways</option><option value="Dallas Outside CPA">Dallas Outside CPA</option><option value="EMPOWER Regular Referral">EMPOWER Regular Referral</option><option value="EMPOWER Priority Grant">EMPOWER Priority Grant</option><option value="Garden of Hope">Garden of Hope</option><option value="Gladney Home">Gladney Home</option><option value="Grace House ">Grace House </option><option value="Guardian's Promise, LLC">Guardian's Promise, LLC</option><option value="Harmony Family Services">Harmony Family Services</option><option value="HCYR - Ingram Campus">HCYR - Ingram Campus</option><option value="HCYR - Leakey Campus">HCYR - Leakey Campus</option><option value="Hope House Clinic">Hope House Clinic</option><option value="Houston CPA Pathways">Houston CPA Pathways</option><option value="Houston Outside CPA">Houston Outside CPA</option><option value="Houston Pathways Clinic">Houston Pathways Clinic</option><option value="Jonathan's Place Dallas">Jonathan's Place Dallas</option><option value="Legacy Ranch Austin">Legacy Ranch Austin</option><option value="MiOwn Home">MiOwn Home</option><option value="North Star RTC Dallas">North Star RTC Dallas</option><option value="Open Hearts Open Arms">Open Hearts Open Arms</option><option value="San Antonio CPA Pathways">San Antonio CPA Pathways</option><option value="San Antonio Outside CPA">San Antonio Outside CPA</option><option value="San Antonio Pathways Clinic">San Antonio Pathways Clinic</option><option value="Seton Home San Antonio">Seton Home San Antonio</option><option value="The Ranch">The Ranch</option><option value="Unbound Now">Unbound Now</option><option value=""></option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_63" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Please list "Other" Referral Source below: / Por favor, indique "otra" fuente de remisión abajo:</label><input name="CST_64" type="text" class="er_fld_blank er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Referral Source's Phone No. / No. de teléfono de la fuente de remisión </label><input name="CST_45" type="text" class="er_fld_required er_fld_width75"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-font"></i><label class="er_fld_label required">Referral Source's Email / Correo electrónico de la fuente de remisión </label><input name="CST_46" type="text" class="er_fld_width75 er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3 er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the client or caregiver aware that a referral has been made on their behalf? / ¿Sabe el cliente o el cuidador que se ha hecho una remisión en su nombre? </label> <label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="Yes / Si">Yes / Si</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="No">No</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="Self Referral / Remisión propia">Self Referral / Remisión propia</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_58" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_58_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=Behavioral+Health+Services+(counseling%2C+skills+training+and%2For+wraparound)+%2F+Servicios+de+salud+conductual+(asesoramiento%2C+entrenamiento+de+habilidades%2C+y%2Fo+servicios+integrales)&er_fld_showif_values=CANS+2.0+(eCANS)+-+Only+initial+%26+annual+assessment+%2F+CANS+2.0+(eCANS)+-+S%C3%B3lo+evaluaci%C3%B3n+inicial+y+anual&er_fld_showif_values=Psychiatric+Services+(medication+management+with+a+doctor)+%2F+Servicios+psiqui%C3%A1tricos+(gesti%C3%B3n+de+medicamentos+con+un+m%C3%A9dico)" er_fld_condfld="CST_22"><i class="fa fa-paragraph"></i><label class="er_fld_label">Please list any additional comments, such as anticipated placement date, if applicable: / Enumere cualquier comentario adicional, como la fecha de colocación prevista, si corresponde:</label><textarea name="CST_47" style="width:100%;" class="er_fld_blank"></textarea></li></ul>
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