Online Referral
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">Client First Name:</label><input name="CST_2" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name:</label><input name="CST_3" type="text" value="" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number:</label><input name="CST_4" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address:</label><input name="CST_5" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address Line 1:</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address Line 2:</label><input name="CST_10" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City:</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County:</label><input name="CST_14" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State:</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_13" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_DOB" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Client Date of Birth:</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Gender"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Gender:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Female">Female</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Male">Male</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_8" value="Prefer Not to Say">Prefer Not to Say</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_8" value="Other:">Other:<input class="cst_Other" name="CST_8_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" map_to="CC_ReferringWorker_Ref" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Referred to Compass By:</label><input name="CST_18" type="text"></li><li class="er_fld_type_text" draggable="false" map_to="CustomField_Value_1" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Parents/Guardian Names</label><input name="CST_17" 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">Please List: Insurance Provider ("N/A" if not applicable) Primary Insr. Carrier's Name Primary Insr. Carrier's DOB Primary Insr. Carrier's Member ID# </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;" map_to="CC_Comments"> <i class="fa fa-paragraph"></i><label class="er_fld_label required"></label><textarea name="CST_27" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Medicaid" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Medicaid # (if applicable):</label><input name="CST_19" type="text" class="er_fld_required er_fld_width100"></li><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">Comments or Additional Information:</label><textarea name="CST_21" style="width:100%;"></textarea></li></ul>
Submit