{"id":1133,"date":"2023-10-20T13:51:17","date_gmt":"2023-10-20T13:51:17","guid":{"rendered":"https:\/\/dtacenters.com\/?page_id=1133"},"modified":"2023-11-17T18:55:38","modified_gmt":"2023-11-17T18:55:38","slug":"referral-profile","status":"publish","type":"page","link":"https:\/\/dtacenters.com\/referral-profile\/","title":{"rendered":"Referral Profile"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_safari gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_19' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">New Referral<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_19'  action='\/wp-json\/wp\/v2\/pages\/1133' data-formid='19' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full disabled-date gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_1\" ><label class='gfield_label gform-field-label' for='input_19_1'>Referral Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_19_1' type='text' value='05\/07\/2024' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection gfield_required gfield_required_text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_127\" ><h3 class=\"gsection_title\">(Required)<\/h3><\/div><fieldset id=\"field_19_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_6'><div class='gchoice gchoice_19_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='IBHS'  id='choice_19_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_1' id='label_19_6_1' class='gform-field-label gform-field-label--type-inline'>IBHS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Extended Evaluations'  id='choice_19_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_2' id='label_19_6_2' class='gform-field-label gform-field-label--type-inline'>Extended Evaluations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='ARRTS'  id='choice_19_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_3' id='label_19_6_3' class='gform-field-label gform-field-label--type-inline'>ARRTS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='PHP'  id='choice_19_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_4' id='label_19_6_4' class='gform-field-label gform-field-label--type-inline'>PHP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='CSBBH'  id='choice_19_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_5' id='label_19_6_5' class='gform-field-label gform-field-label--type-inline'>CSBBH<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='OP Psych'  id='choice_19_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_6_6' id='label_19_6_6' class='gform-field-label gform-field-label--type-inline'>OP Psych<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_4'><div class='gchoice gchoice_19_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='CCBH-NC'  id='choice_19_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_4_1' id='label_19_4_1' class='gform-field-label gform-field-label--type-inline'>CCBH-NC<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='PerformCare'  id='choice_19_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_4_2' id='label_19_4_2' class='gform-field-label gform-field-label--type-inline'>PerformCare<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='CCBH-LY'  id='choice_19_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_4_3' id='label_19_4_3' class='gform-field-label gform-field-label--type-inline'>CCBH-LY<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='FFS'  id='choice_19_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_4_4' id='label_19_4_4' class='gform-field-label gform-field-label--type-inline'>FFS<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_7\" ><label class='gfield_label gform-field-label' for='input_19_7'>Referring Agent \/ Relationship to Client:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_19_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_8\" ><label class='gfield_label gform-field-label' for='input_19_8'>Referring Agent\u2019s #:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_19_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_9\" ><label class='gfield_label gform-field-label' for='input_19_9'>CLIENT NAME:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_19_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_10'><div class='gchoice gchoice_19_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Male'  id='choice_19_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_1' id='label_19_10_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Female'  id='choice_19_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_2' id='label_19_10_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_11\" ><label class='gfield_label gform-field-label' for='input_19_11'>D.O.B.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_19_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_12\" ><label class='gfield_label gform-field-label' for='input_19_12'>AGE:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_19_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_35\" ><label class='gfield_label gform-field-label' for='input_19_35'>Social Security #:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_19_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_36\" ><label class='gfield_label gform-field-label' for='input_19_36'>MA# \/ Card Issue:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_19_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_15\" ><label class='gfield_label gform-field-label' for='input_19_15'>HOME ADDRESS:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_19_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_16\" ><label class='gfield_label gform-field-label' for='input_19_16'>COUNTY:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_19_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_17\" ><label class='gfield_label gform-field-label' for='input_19_17'>Home School District:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_19_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_18\" ><label class='gfield_label gform-field-label' for='input_19_18'>School Attending:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_19_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_19\" ><label class='gfield_label gform-field-label' for='input_19_19'>Grade:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_19_19' type='text' value='' class='large'    placeholder='4th' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_37\" ><label class='gfield_label gform-field-label' for='input_19_37'>School Contact Person \/ Title:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_19_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_20\" ><label class='gfield_label gform-field-label' for='input_19_20'>Phone # \/ Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_19_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_68\" ><h3 class=\"gsection_title\">LIST ANY AGENCIES CURRENTLY INVOLVED BELOW (MH\/BHIDS, CYS, JPO, etc.)<\/h3><\/div><div id=\"field_19_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_44\" ><label class='gfield_label gform-field-label' for='input_19_44'>AGENCY \/ COUNTY (REQUIRED IF APPLICABLE):<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_19_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_45\" ><label class='gfield_label gform-field-label' for='input_19_45'>CASE MANAGER \/ TITLE (REQUIRED IF APPLICABLE):<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_19_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_46\" ><label class='gfield_label gform-field-label' for='input_19_46'>PHONE # \/ EMAIL (REQUIRED IF APPLICABLE):<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_19_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_71\" ><label class='gfield_label gform-field-label' for='input_19_71'>AGENCY \/ COUNTY<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_19_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_72\" ><label class='gfield_label gform-field-label' for='input_19_72'>CASE MANAGER \/ TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_19_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_73\" ><label class='gfield_label gform-field-label' for='input_19_73'>PHONE # \/ EMAIL<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_19_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_74\" ><label class='gfield_label gform-field-label' for='input_19_74'>AGENCY \/ COUNTY<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_19_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_75\" ><label class='gfield_label gform-field-label' for='input_19_75'>CASE MANAGER \/ TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_19_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_77\" ><label class='gfield_label gform-field-label' for='input_19_77'>PHONE # \/ EMAIL<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_19_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_78\" ><label class='gfield_label gform-field-label' for='input_19_78'>AGENCY \/ COUNTY<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_19_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_79\" ><label class='gfield_label gform-field-label' for='input_19_79'>CASE MANAGER \/ TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_19_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_80\" ><label class='gfield_label gform-field-label' for='input_19_80'>PHONE # \/ EMAIL<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_19_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_81\" ><label class='gfield_label gform-field-label' for='input_19_81'>AGENCY \/ COUNTY<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_19_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_82\" ><label class='gfield_label gform-field-label' for='input_19_82'>CASE MANAGER \/ TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_19_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_83\" ><label class='gfield_label gform-field-label' for='input_19_83'>PHONE # \/ EMAIL<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_19_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_84\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_84\" ><h3 class=\"gsection_title\">PARENTS &amp; GUARDIANS *Please specify legal guardianship (if applicable\/CYS)*<\/h3><\/div><div id=\"field_19_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_85\" ><label class='gfield_label gform-field-label' for='input_19_85'>NAME \/ RELATIONSHIP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_19_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_86\" ><label class='gfield_label gform-field-label' for='input_19_86'>PHONE # \/ Type (Cell \/ Home \/ Work)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_19_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_89\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_89\" ><label class='gfield_label gform-field-label' for='input_19_89'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_89' id='input_19_89' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_90\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_90\" ><label class='gfield_label gform-field-label' for='input_19_90'>NAME \/ RELATIONSHIP<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_19_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_91\" ><label class='gfield_label gform-field-label' for='input_19_91'>PHONE # \/ Type (Cell \/ Home \/ Work)<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_19_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_92\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_92\" ><label class='gfield_label gform-field-label' for='input_19_92'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_92' id='input_19_92' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_93\" ><label class='gfield_label gform-field-label' for='input_19_93'>NAME \/ RELATIONSHIP<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_19_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_94\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_94\" ><label class='gfield_label gform-field-label' for='input_19_94'>PHONE # \/ Type (Cell \/ Home \/ Work)<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_19_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_95\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_95\" ><label class='gfield_label gform-field-label' for='input_19_95'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_95' id='input_19_95' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_96\" ><label class='gfield_label gform-field-label' for='input_19_96'>NAME \/ RELATIONSHIP<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_19_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_97\" ><label class='gfield_label gform-field-label' for='input_19_97'>PHONE # \/ Type (Cell \/ Home \/ Work)<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_19_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_98\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_98\" ><label class='gfield_label gform-field-label' for='input_19_98'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_98' id='input_19_98' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_99\" ><label class='gfield_label gform-field-label' for='input_19_99'>NAME \/ RELATIONSHIP<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_19_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_100\" ><label class='gfield_label gform-field-label' for='input_19_100'>PHONE # \/ Type (Cell \/ Home \/ Work)<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_19_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_101\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_101\" ><label class='gfield_label gform-field-label' for='input_19_101'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_101' id='input_19_101' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_19_102\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_102\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_102'><div class='gchoice gchoice_19_102_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.1' type='checkbox'  value='Yes'  id='choice_19_102_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_102_1' id='label_19_102_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_102_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.2' type='checkbox'  value='No'  id='choice_19_102_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_102_2' id='label_19_102_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_103\" ><label class='gfield_label gform-field-label' for='input_19_103'>Best Time to Call \/ Schedule?<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_19_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_104\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_104\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_104'><div class='gchoice gchoice_19_104_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.1' type='checkbox'  value='Yes'  id='choice_19_104_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_104_1' id='label_19_104_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_104_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.2' type='checkbox'  value='No'  id='choice_19_104_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_104_2' id='label_19_104_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_105\" ><label class='gfield_label gform-field-label' for='input_19_105'>Best Time to Call \/ Sched<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_19_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_106\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_106\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_106'><div class='gchoice gchoice_19_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Yes'  id='choice_19_106_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_106_1' id='label_19_106_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='No'  id='choice_19_106_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_106_2' id='label_19_106_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_107\" ><label class='gfield_label gform-field-label' for='input_19_107'>Best Time to Call \/ Sched<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_19_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_108\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_108\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_108'><div class='gchoice gchoice_19_108_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.1' type='checkbox'  value='Yes'  id='choice_19_108_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_108_1' id='label_19_108_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_108_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.2' type='checkbox'  value='No'  id='choice_19_108_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_108_2' id='label_19_108_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_109\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_109\" ><label class='gfield_label gform-field-label' for='input_19_109'>Best Time to Call \/ Sched<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_19_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_110\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_110\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Employed?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_110'><div class='gchoice gchoice_19_110_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.1' type='checkbox'  value='Yes'  id='choice_19_110_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_110_1' id='label_19_110_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_110_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.2' type='checkbox'  value='No'  id='choice_19_110_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_110_2' id='label_19_110_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_111\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_111\" ><label class='gfield_label gform-field-label' for='input_19_111'>Best Time to Call \/ Sched<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_19_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_112\" ><label class='gfield_label gform-field-label' for='input_19_112'>SIBLINGS<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_19_112' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_113\" ><label class='gfield_label gform-field-label' for='input_19_113'>AGE<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_19_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_114\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_114\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In the Home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_114'><div class='gchoice gchoice_19_114_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.1' type='checkbox'  value='Yes'  id='choice_19_114_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_114_1' id='label_19_114_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_114_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.2' type='checkbox'  value='No'  id='choice_19_114_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_114_2' id='label_19_114_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_115\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_115\" ><label class='gfield_label gform-field-label' for='input_19_115'>SIBLINGS<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_19_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_116\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_116\" ><label class='gfield_label gform-field-label' for='input_19_116'>AGE<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_19_116' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_117\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_117\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In the Home?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_117'><div class='gchoice gchoice_19_117_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.1' type='checkbox'  value='Yes'  id='choice_19_117_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_1' id='label_19_117_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_117_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.2' type='checkbox'  value='No'  id='choice_19_117_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_117_2' id='label_19_117_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_118\" ><label class='gfield_label gform-field-label' for='input_19_118'>SIBLINGS<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_19_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_119\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_119\" ><label class='gfield_label gform-field-label' for='input_19_119'>AGE<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_19_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_120\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In the Home?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_120'><div class='gchoice gchoice_19_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='Yes'  id='choice_19_120_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_120_1' id='label_19_120_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='No'  id='choice_19_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_120_2' id='label_19_120_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_121\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_121\" ><label class='gfield_label gform-field-label' for='input_19_121'>SIBLINGS<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_19_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_19_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_122\" ><label class='gfield_label gform-field-label' for='input_19_122'>AGE<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_19_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_19_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_2col field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_123\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In the Home?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_19_123'><div class='gchoice gchoice_19_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Yes'  id='choice_19_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_123_1' id='label_19_123_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='No'  id='choice_19_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_123_2' id='label_19_123_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_47\" ><label class='gfield_label gform-field-label' for='input_19_47'>PRESENTING PROBLEMS \/ TRAUMA HISTORY:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_19_47' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_48\" ><label class='gfield_label gform-field-label' for='input_19_48'>LEVEL OF FAMILY PARTICIPATION:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_19_48' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_49\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_49\" ><label class='gfield_label gform-field-label' for='input_19_49'>SCHOOL HISTORY (IF APPLICABLE):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_19_49' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_50\" ><label class='gfield_label gform-field-label' for='input_19_50'>Notes:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_19_50' class='textarea large'    placeholder='Does client require any additional accommodation in order to participate in therapeutic activities?_____ If &quot;yes&quot;, please describe the nature of the accommodation needed:'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_19_129\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full fileuploadclass field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_19_129\" ><label class='gfield_label gform-field-label' for='gform_browse_button_19_129'>Please upload any additional relevant documents<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_19_129' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_19_129&quot;,&quot;container&quot;:&quot;gform_multifile_upload_19_129&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_19_129&quot;,&quot;filelist&quot;:&quot;gform_preview_19_129&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/dtacenters.com\\\/?gf_page=d3def286de579bc&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/dtacenters.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/dtacenters.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf,doc,docx,xlx,png,jpeg,jpg,&quot;}],&quot;max_file_size&quot;:&quot;104857600b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:19,&quot;field_id&quot;:129},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_19_129&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_19_129' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_19_129' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_19_129\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_19_129'>Accepted file types: pdf, doc, docx, xlx, png, jpeg, jpg, , Max. file size: 100 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_19_129'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_19_129' class='ginput_preview_list'><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_19' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_19\"]){return false;}  if( !jQuery(\"#gform_19\")[0].checkValidity || jQuery(\"#gform_19\")[0].checkValidity()){window[\"gf_submitting_19\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_19\"]){return false;} if( !jQuery(\"#gform_19\")[0].checkValidity || jQuery(\"#gform_19\")[0].checkValidity()){window[\"gf_submitting_19\"]=true;}  jQuery(\"#gform_19\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_19' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='19' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_19' 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