Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_ReferralSource_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Where did you hear about us?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Community Provider/School">Community Provider/School</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Court/CDW">Court/CDW</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="DCBS">DCBS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Hospital/Medical Office">Hospital/Medical Office</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Online/Holly Hill Website">Online/Holly Hill Website</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Other Holly Hill Program">Other Holly Hill Program</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Previous Holly Hill Client">Previous Holly Hill Client</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Relative">Relative</label><label class="er_option"><input class="type_radio" type="radio" name="CST_6" value="Residential Facility">Residential Facility</label><label class="er_option er_option_other"><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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Preferred Name</label><input name="CST_7" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_3" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Gender"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_4" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Race"> <i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_5" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Unknown">Unknown</option><option value="African American">African American</option><option value="Asian/Pacific Islander">Asian/Pacific Islander</option><option value="Bi-Racial">Bi-Racial</option><option value="Caucasian">Caucasian</option><option value="Native American">Native American</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_selected" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Identified Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Gender Neutral">Gender Neutral</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_radio" type="radio" name="CST_67" value="Transgender">Transgender</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_67" value="Other:">Other:<input class="cst_Other" name="CST_67_Other" type="text"></label></li><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Preferred Pronouns</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="He/Him/His">He/Him/His</label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="She/Her/Hers">She/Her/Hers</label><label class="er_option"><input class="type_radio" type="radio" name="CST_8" value="They/Them/Theirs">They/Them/Theirs</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_8" value="Other:">Other:<input class="cst_Other" name="CST_8_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Language"><i class="fa fa-circle-o"></i><label class="er_fld_label">Language</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_65" value="English" checked="">English</label><label class="er_option"><input class="type_radio" type="radio" name="CST_65" value="Spanish">Spanish</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_65" value="Other:">Other:<input class="cst_Other" name="CST_65_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Primary language spoken at home</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_66" value="English" checked="">English</label><label class="er_option"><input class="type_radio" type="radio" name="CST_66" value="Spanish">Spanish</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other" name="CST_66_Other" type="text"></label></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">Address</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip</label><input name="CST_14" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label">Mobile Phone Number</label><input name="CST_16" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">School</label><input name="CST_20" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Grade</label><input name="CST_21" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is there active DCBS/DJJ involvement?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_69" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_69" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_69_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_69" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">In what county?</label><input name="CST_73" 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: 100%;" er_fld_condfld="CST_69" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Worker Name</label><input name="CST_70" 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: 33.3333%;" er_fld_condfld="CST_69" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Worker Phone Number</label><input name="CST_71" 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_69" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Worker Email Address</label><input name="CST_72" type="text" class="er_fld_blank"></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>Insurance Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Will you be using an EAP benefit?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_26" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_26" 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_26" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_26_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_26" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">EAP Information</label><textarea name="CST_28" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Primary Insurance</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Provider</label><input name="CST_22" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Member ID</label><input name="CST_24" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Subscriber Name (if other than client)</label><input name="CST_30" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Subscriber Date of Birth (if other than client)</label><input name="CST_31" 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">Secondary Insurance</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Provider</label><input name="CST_23" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Member ID</label><input name="CST_25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Subscriber Name (if other than client)</label><input name="CST_32" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Subscriber Date of Birth (if other than client)</label><input name="CST_33" type="text"></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">Who is financially responsible for charges not covered by insurance?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_35" value="Client">Client</label><label class="er_option"><input class="type_radio" type="radio" name="CST_35" value="Parent/Guardian">Parent/Guardian</label><label class="er_option er_option_other"><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></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 client a minor?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_42" 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_42" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_42_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_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-header"></i><label>Parent/Guardian Information</label><hr></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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Primary</div></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_Name_First_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">First Name</label><input name="CST_37" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name</label><input name="CST_38" 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: 33.3333%;" map_to="CC_Phone_Mobile_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Mobile Phone Number</label><input name="CST_39" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Home_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Home Phone Number</label><input name="CST_40" 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: 33.3333%;" map_to="CC_EMail_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_41" 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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Client</label><input name="CST_45" 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%;" map_to="CC_Address_Street_1_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address (if other than client's)</label><input name="CST_46" 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: 20%;" map_to="CC_Address_City_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_47" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_Address_State_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_48" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_Address_Zip_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_49" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" map_to="CC_Address_County_B" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">County</label><input name="CST_50" type="text"></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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Secondary</div></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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">First Name</label><input name="CST_54" 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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name</label><input name="CST_55" 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: 33.3333%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Mobile Phone Number</label><input name="CST_56" 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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Home Phone Number</label><input name="CST_57" 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: 33.3333%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_58" 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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Client</label><input name="CST_59" 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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Address (if other than client's)</label><input name="CST_60" 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: 20%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_62" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_61" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Zip</label><input name="CST_63" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">County</label><input name="CST_64" type="text" class="er_fld_blank"></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_42" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">* If applicable, please provide documentation of custody arrangements at intake.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-header"></i><label>Emergency Contact Information</label><hr></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_42" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_51" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship to Client</label><input name="CST_53" 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_42" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number</label><input name="CST_52" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_42" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_74" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Briefly describe Presenting Problem(s):</label><textarea name="CST_68" style="width:100%;"></textarea></li></ul>
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