Online Referral

Click the 'Generate Form' link to pre-populate the form when you are ready.

<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Referrer Information </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label required">Is this a self referral?</label><select name="CST_32" class="er_fld_width100 er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" map_to="Nothing" style="width: 100%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Family Informed of Referral </label><select name="CST_5" class=""><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringWorker_Ref" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's 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 er_fld_showif" draggable="false" style="width: 100%;" map_to="CC_ReferralSource_Ref" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-font"></i><label class="er_fld_label">Referral Agency </label><input name="CST_1" type="text" class=""></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_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-font"></i><label class="er_fld_label required">Referrer's email</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Referrer's Number</label><input name="CST_4" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" map_to="CC_ReferralReason_Ref">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for Referral </label><textarea name="CST_6" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Family 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 er_fld_fontstyle_normal">Primary Caregiver's (PC) Information </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First">
<i class="fa fa-font"></i><label class="er_fld_label required">First Name </label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last">
<i class="fa fa-font"></i><label class="er_fld_label required">Last Name </label><input name="CST_8" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 50%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
		<i class="fa fa-font"></i><label class="er_fld_label">Email address</label><input name="CST_34" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_Street_1">
<i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_10" type="text"></li><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">City</label><input name="CST_11" type="text"></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">Zip</label><input name="CST_13" type="text" class="er_fld_blank"></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_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB">
<i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth</label><input class="cst_datepicker" name="CST_15" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Language">
<i class="fa fa-font"></i><label class="er_fld_label">Primary language in home </label><input name="CST_14" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
		<i class="fa fa-caret-down"></i><label class="er_fld_label">Currently pregnant?</label><select name="CST_33"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 33.3333%;" map_to="CC_Medicaid">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Medicaid or is Uninsured</label><select name="CST_16"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unknown">Unknown</option></select></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_normal">Youngest Child Information </div></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">First Name </label><input name="CST_18" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;">
<i class="fa fa-font"></i><label class="er_fld_label">Last Name </label><input name="CST_19" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker" name="CST_20" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Does Child Have Medicaid or is Uninsured </label><select name="CST_21"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Additional Family Information </label><textarea name="CST_31" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">What sevices are you interested in? (check all that apply)</label>
		
   		
   		
   		
   <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="First Steps Georgia/ Community Resources">First Steps Georgia/ Community Resources</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Georgia Home Visiting/ Healthy Families ">Georgia Home Visiting/ Healthy Families </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_36" value="Other Wellroot Services">Other Wellroot Services</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_36" value="Other:">Other:<input class="cst_Other" name="CST_36_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_normal">DFCS Referrals </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-caret-down"></i><label class="er_fld_label">DFCS Referral Source </label><select name="CST_26"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="OFI">OFI</option><option value="Intake (Screen Out Only)">Intake (Screen Out Only)</option><option value="Investigations">Investigations</option><option value="Family Support Service (FSS)">Family Support Service (FSS)</option><option value="Family Preservation Service (FPS)">Family Preservation Service (FPS)</option><option value="Foster Care ">Foster Care </option><option value="Resource Development">Resource Development</option><option value="Adoptions ">Adoptions </option></select></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Current Open CPS Case</label><select name="CST_27"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-caret-down"></i><label class="er_fld_label">Closed CPS Case </label><select name="CST_28"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 50%;" draggable="false" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Plan of Safe Care (check all that apply)</label>

<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="N/A">N/A</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="POSC has been completed by DFCS">POSC has been completed by DFCS</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="POSC monitoring by HFNG requested ">POSC monitoring by HFNG requested </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="DFCS requesting POSC completion by HFNG ">DFCS requesting POSC completion by HFNG </label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_29" value="Other:">Other:<input class="cst_Other" name="CST_29_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small sortable-chosen" draggable="true" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Additional Details for Referral</label><textarea name="CST_30" style="width:100%;"></textarea></li></ul>