Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Therapeutic Referral Form</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Please Complete This Form in its Entirety</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="Nothing" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did your hear about 4KIDS?</label><select name="CST_1" class="er_fld_required"><option value="Select" selected="">Select</option><option value="Website">Website</option><option value="Staff Member">Staff Member</option><option value="Church Presentation">Church Presentation</option><option value="Friend">Friend</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label">If Church Presentation, Please list church</label><input name="CST_44" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If Friend, Please provide their name</label><input name="CST_43" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">If Other, Please specify</label><input name="CST_8" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Client Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Name_First" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Client First Name:</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Name_Last" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Client Last Name:</label><input name="CST_3" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client Gender:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_4" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_4" value="Female">Female</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_4" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_4_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Client Race:</label><select name="CST_5" class="er_fld_required"><option value="Select" selected="">Select</option><option value="American Indian or Alaskan Native">American Indian or Alaskan Native</option><option value="Asian">Asian</option><option value="Black or African American">Black or African American</option><option value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</option><option value="White">White</option><option value="Multiracial">Multiracial</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the child of Hispanic Origin?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_6" 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_6" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_6_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 50%;"><i class="fa fa-calendar"></i><label class="er_fld_label required">Client Date of Birth:</label><input class="cst_datepicker er_fld_required" name="CST_7" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"><i class="fa fa-font"></i><label class="er_fld_label required">Client Street Address:</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">Client City:</label><input name="CST_19" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_State"><i class="fa fa-font"></i><label class="er_fld_label required">Client State:</label><input name="CST_20" type="text" value="FL" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Zip"><i class="fa fa-font"></i><label class="er_fld_label required">Client Zip Code:</label><input name="CST_21" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_Address_County"><i class="fa fa-font"></i><label class="er_fld_label required">Client County:</label><input name="CST_22" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Referral Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Who is filling out this form?</label><select name="CST_9" class="er_fld_required"><option value="Select" selected="">Select</option><option value="Foster Parent">Foster Parent</option><option value="Adoptive Parent">Adoptive Parent</option><option value="Biological Parent">Biological Parent</option><option value="Foster Care Team">Foster Care Team</option><option value="School">School</option><option value="Community">Community</option><option value="Church">Church</option><option value="Self">Self</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">If other, Please Specifiy:</label><input name="CST_16" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Referral Reason:</label><select name="CST_42" class="er_fld_required"><option value="Select" selected="">Select</option><option value="Foster Care Placement">Foster Care Placement</option><option value="Trauma">Trauma</option><option value="Behavior">Behavior</option><option value="Transition">Transition</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" map_to="CustomField_Value_8" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label required">Brief description of behaviors, actions, and/or circumstances prompting this referral:</label><textarea name="CST_10" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is client currently seeing therapy elsewhere?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" 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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label> </li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, where?</label><input name="CST_46" type="text"></li><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Are you planning to end that therapeutic relationship and transfer to 4KIDS?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_47" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_47" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_47" value="Other:">Other:<input class="cst_Other" name="CST_47_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 100%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Please select your preference for services:</label><select name="CST_49" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="TeleMed Only">TeleMed Only</option><option value="TeleMed or In-Person">TeleMed or In-Person</option><option value="In-Person Only">In-Person Only</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Your Title</label><select name="CST_11" class="er_fld_required"><option value="Select" selected="">Select</option><option value="Mr.">Mr.</option><option value="Mrs.">Mrs.</option><option value="Ms.">Ms.</option><option value="Pastor">Pastor</option><option value="Dr. ">Dr. </option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CustomField_Value_4"><i class="fa fa-font"></i><label class="er_fld_label required">Your First Name:</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CustomField_Value_2"><i class="fa fa-font"></i><label class="er_fld_label required">Your Last Name:</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CustomField_Value_3"><i class="fa fa-font"></i><label class="er_fld_label required">Your Mobile #:</label><input name="CST_14" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CustomField_Value_5"><i class="fa fa-font"></i><label class="er_fld_label required">Your Email:</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Caregiver Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you the Caregiver?:</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_17" 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_17" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_17_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CustomField_Value_2"><i class="fa fa-font"></i><label class="er_fld_label">If no, What is the Caregiver's first and last name?:</label><input name="CST_23" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_3"><i class="fa fa-font"></i><label class="er_fld_label">Caregiver Mobile #:</label><input name="CST_24" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_5"><i class="fa fa-font"></i><label class="er_fld_label">Caregiver Email:</label><input name="CST_25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Family Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CustomField_Value_6"><i class="fa fa-caret-down"></i><label class="er_fld_label required"># of children in home under age 18:</label><select name="CST_40" class="er_fld_required"><option value="0">0</option><option value="1" selected="">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="10+">10+</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CustomField_Value_7"><i class="fa fa-caret-down"></i><label class="er_fld_label required"># of people age 18 and over in home:</label><select name="CST_41" class="er_fld_required"><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="10+">10+</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Best Time to Call:</label><select name="CST_28" class="er_fld_required"><option value="Select" selected="">Select</option><option value="8AM-Noon">8AM-Noon</option><option value="Noon-5PM">Noon-5PM</option><option value="5PM-9PM">5PM-9PM</option><option value="Anytime">Anytime</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false" map_to="CC_Income"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Household Income</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="A: BELOW - $5000">A: BELOW - $5000</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="B: $5000 - $9999">B: $5000 - $9999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="C: $10000 - $14999">C: $10000 - $14999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="D: $15000 - $24999">D: $15000 - $24999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="E: $25000 - $34999">E: $25000 - $34999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="F: $35000 - $49999">F: $35000 - $49999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="G: $50000 - $74999">G: $50000 - $74999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="H: $75000 - $99999">H: $75000 - $99999</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_48" value="I: $100000 & ABOVE">I: $100000 & ABOVE</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_48" value="Other:">Other:<input class="cst_Other" name="CST_48_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 er_fld_fontstyle_bold">Team Members</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If you have a 4KIDS support worker please include their contact information below:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_34" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Work Number</label><input name="CST_35" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_36" type="text"></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">If you have a ChildNet or Communities Connected for Kids support worker please include their contact information below:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_37" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Work Number</label><input name="CST_38" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_39" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Insurance Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If you do not have insurance, please write "No Insurance" in the blanks below. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="Nothing" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Insurance/Medicaid Company Name</label><input name="CST_31" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Medicaid"><i class="fa fa-font"></i><label class="er_fld_label required">Insurance/Medicaid ID Number</label><input name="CST_33" type="text" class="er_fld_required"></li></ul>
Submit