Online Referral
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<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_noprint er_fld_fontstyle_info">SAFE Net / Refugees Northwest UPDATED REFERRAL & WAITLIST POLICIES SAFE Net prioritizes evaluation requests for applicants who are: [1] not currently in detention; [2] have set court dates / interview dates / ICH dates; [3] are being represented pro-bono or low-bono in their immigration case; [4] have an annual household income at or below 200% of the 2023 federal poverty level; and [5] have a Seattle connection separate from the asylum process - meaning they either live, work, volunteer, go to school, or participate in community organizations within Seattle city limits. Unfortunately, we can't count Seattle Immigration Court, USCIS, or the location of legal offices as Seattle connections. In limited cases, we may be able to facilitate an evaluation for an applicant without a Seattle connection, but only if no assistance with interpretation is required (e.g. the applicant is fluent in English, their attorney agrees to arrange professional interpretation with a service on our approved list, or an evaluator in our network that's fluent in the applicant's preferred language has availability). We are unable to consider requests for full fee clients. If you would like to receive more information about alternative psychological evaluation services for paying clients, please contact us at evalnetteam@lcsnw.org. More information about our program's policies and procedures can be found at our new website: https://sites.google.com/lcsnw.org/safenet/evaluations. Please update any previous bookmarks. COMPLETING YOUR REFERRAL The referral form below must be filled out by the applicant's attorney, a paralegal or an assistant, or another member of the representing organization. Applicants may not refer themselves. Fields marked with an asterisk are required. Before beginning the form, please be prepared to specify the applicant's household size and household income as part of complying with Washington state assistance guidelines. In addition to submitting the referral form, we require a signed ROI (see: below), your client's declaration or a draft declaration, and preferably the full I-589 form. Please email these and any other documents that may be helpful to evalnetteam@lcsnw.org. Please use the email subject line "EN Referral Applicant - Applicant's Initials - Partner Organization". (Example: EN Referral Applicant - XYZ - Partner Organization.) We recommend sending documents securely. If you don't have access to digital encryption, let us know you have material ready to send and we'll reply with an encrypted thread that accepts attachments A copy of our current ROI can be found here: https://drive.google.com/file/d/1DCwOhuSufj5frTjdXR7f7dQNLxHkt8Fq/view?usp=share_link We will be unable to process your referral until all documentation is received. COVID-19 RESPONSE Currently, all of our psychological evaluation appointments are conducted remotely via secure video calls - usually Google Meet. We are also scheduling in-person medical appointments, with priority given to applicants with court / interview / filing deadlines within 6 months.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"><i class="fa fa-pencil"></i><label class="er_fld_label required">I have read and agree to the the Evaluation Network's Policies and Procedures - Signature</label><div class="cst_signaturepad"></div><input name="CST_55" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Required Documentation</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_80" value="I submitted a signed Release of Information, Declaration, and any other documents relevant to potential evaluators to evalnetteam@lcsnw.org">I submitted a signed Release of Information, Declaration, and any other documents relevant to potential evaluators to evalnetteam@lcsnw.org</label><label class="er_option"><input class="type_radio" type="radio" name="CST_80" value="I will submit the necessary documents to evalnetteam@lcsnw.org after completing this form">I will submit the necessary documents to evalnetteam@lcsnw.org after completing this form</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_80" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_80_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>Services Requested (Required)</label><hr></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_Category_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Evaluation Request:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="Psychological">Psychological</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="Medical ">Medical </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_11" value="Psychological & Medical">Psychological & Medical</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_11" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_11_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CustomField_Value_5"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Case Type(s)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Asylum - Affirmative">Asylum - Affirmative</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Asylum - Derivative">Asylum - Derivative</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Asylum - Defensive">Asylum - Defensive</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="SIJ">SIJ</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Withholding of Removal">Withholding of Removal</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="C.A.T.">C.A.T.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_Other" type="text"></label></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 required">Client Type</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_56" value="Pro-bono">Pro-bono</label><label class="er_option"><input class="type_radio" type="radio" name="CST_56" value="Low-bono">Low-bono</label><label class="er_option"><input class="type_radio" type="radio" name="CST_56" value="Full Fee (we are unable to accept full fee referrals at this time)">Full Fee (we are unable to accept full fee referrals at this time)</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_56" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_56_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 required">Amount Charged to Applicant for Representation (approximate)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="Full Standard Fee">Full Standard Fee</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="76-99% of your standard fees">76-99% of your standard fees</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="51-75% of your standard fees">51-75% of your standard fees</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="25-50% of your standard fees">25-50% of your standard fees</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="<25% of your standard fees"><25% of your standard fees</label><label class="er_option"><input class="type_radio" type="radio" name="CST_58" value="None ">None </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_58" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_58_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Special Considerations</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Female Evaluator Preferred">Female Evaluator Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Male Evaluator Preferred">Male Evaluator Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="LGBTQIA+ Specialist Needed">LGBTQIA+ Specialist Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Indigenous Community Member">Indigenous Community Member</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Pediatric Specialist Requested">Pediatric Specialist Requested</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Geriatric Specialist Requested">Geriatric Specialist Requested</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Applicant is Currently Detained">Applicant is Currently Detained</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Applicant Was Previously Detained in the U.S.">Applicant Was Previously Detained in the U.S.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Expedited Case (<12 weeks until filing deadline)">Expedited Case (<12 weeks until filing deadline)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="Dedicated Docket">Dedicated Docket</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_2" value="None">None</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_2" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_2_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false" map_to="CustomField_Value_3"><i class="fa fa-circle-o"></i><label class="er_fld_label required">*Professional Interpretation Provision (Note: it is first and foremost the referring law firm’s responsibility to provide professional interpretation services for all evaluations)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="N/A - Fluent English speaker">N/A - Fluent English speaker</label><label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="Attorney will arrange professional interpretation">Attorney will arrange professional interpretation</label><label class="er_option"><input class="type_radio" type="radio" name="CST_41" value="[Psychological Evaluations only] SAFE Net assistance required">[Psychological Evaluations only] SAFE Net assistance required</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_41" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_41_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_Language"><i class="fa fa-font"></i><label class="er_fld_label required">Preferred Language During Evaluation</label><input name="CST_23" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Additional Languages Known By Applicant</label><input name="CST_24" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"><i class="fa fa-paragraph"></i><label class="er_fld_label required">Are there any days or times when your client is NOT available for evaluation?</label><textarea name="CST_67" style="width:100%;" class="er_fld_required er_fld_desc"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Testimonies Requested (If Applicable)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_9" value="Testimony Request is Unlikely">Testimony Request is Unlikely</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_9" value="Testimony Request: Status Unknown ">Testimony Request: Status Unknown </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_9" value="Psych Evaluator's Testimony Requested">Psych Evaluator's Testimony Requested</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_9" value="Medical Evaluator's Testimony Requested">Medical Evaluator's Testimony Requested</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_9" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_9_Other" type="text"></label></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 required">Filing Deadline</label><input name="CST_6" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label required">ICH or USCIS Interview Date and Time</label><input name="CST_7" type="text" value="" class="er_fld_required"></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">ICH Location (If Applicable)</label><input name="CST_13" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Judge (If Applicable)</label><input name="CST_14" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox sortable-chosen" style="white-space: normal; width: 50%;" draggable="true"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Required/Additional Documents</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="*Release of Information (ROI)">*Release of Information (ROI)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="*Full Draft of Declaration">*Full Draft of Declaration</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="I-589">I-589</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="Medical Records">Medical Records</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="Additional Court Documents">Additional Court Documents</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_68" value="Police Reports">Police Reports</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_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>Critical Case Information:</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Case Status and Timeline Examples (For Referring Attorneys' Reference): *Confirm the I-589 has been submitted. *State deadlines: filing deadline, ICH or USCIS Interview date. </div></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 required"></label><textarea name="CST_3" style="width:100%;" class="er_fld_required"></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_info">Case Summary Please develop a case summary. Having an accurate case summary is crucial for the matching process as this helps our team match cases with the most capable evaluator at a quicker pace. Example: [applicant/applicant initials] is a [age range] individual seeking asylum from [region/country] based on [race, religion, nationality, membership in a particular social group or political opinion]. e.g. Asylum based on PSG: the applicant was arrested and tortured because of their imputed sexual identity</div></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 required"></label><textarea name="CST_4" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Criminal History in U.S.</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_90" value="Yes (please specify)">Yes (please specify)</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_90" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_90_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_91" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Psychological Evaluation Goals (If Applicable)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">Our evaluators are unable to: Determine whether the applicant's criminal charges were related to a mental health disorder and/or past traumas (i.e. "diminished capacity"). Whether the applicant committed a crime because they have a mental illness (i.e. "reasons of insanity"). Assess the "dangerousness" of the applicant. Determine the likelihood that the applicant will use or abuse substances in the future. Determine whether the applicant is lying or telling the truth. *Please contact the Evaluation Program's administrators directly if you would like your client's competence assessed. We may be able to connect you to outside evaluators with this specialty.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please have the psychological evaluator assess for:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Traumatic Brain Injury due to torture or persecution (head injury or loss of consciousness reported)">Traumatic Brain Injury due to torture or persecution (head injury or loss of consciousness reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Traumatic Brain Injury unrelated to asylum grounds (head injury or loss of consciousness reported)">Traumatic Brain Injury unrelated to asylum grounds (head injury or loss of consciousness reported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="General psychological symptoms or disorders associated with the reported traumas">General psychological symptoms or disorders associated with the reported traumas</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Memory problems (impairment suspected)">Memory problems (impairment suspected)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Cognitive issues (impairment suspected)">Cognitive issues (impairment suspected)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Developmental disorders or disabilities (impairment suspected)">Developmental disorders or disabilities (impairment suspected)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Past/ongoing substance use and related disorders (use/disorder suspected)">Past/ongoing substance use and related disorders (use/disorder suspected)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Signs of malingering">Signs of malingering</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_61" value="Other:">Other:<input class="cst_Other" name="CST_61_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please have the psychological evaluator note:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any psychological symptoms that may have contributed to the applicant's delay in their case application">Any psychological symptoms that may have contributed to the applicant's delay in their case application</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any psychological symptoms that may have contributed to the applicant's delay in reporting case details.">Any psychological symptoms that may have contributed to the applicant's delay in reporting case details.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any clinical hardship or consequences likely to occur if the applicant is removed (deported)">Any clinical hardship or consequences likely to occur if the applicant is removed (deported)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any clinical factors that may have contributed to narrative/report discrepancies ">Any clinical factors that may have contributed to narrative/report discrepancies </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any "resiliency" factors that may have contributed to the applicants current mental health/well being ">Any "resiliency" factors that may have contributed to the applicants current mental health/well being </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any clinical observations regarding the applicant's gender identity">Any clinical observations regarding the applicant's gender identity</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any clinical observations regarding the applicant's sexuality">Any clinical observations regarding the applicant's sexuality</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Any clinical recommendations regarding hearing accommodations or safeguards">Any clinical recommendations regarding hearing accommodations or safeguards</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="The significance and prognosis of the applicant's symptoms/disorder ">The significance and prognosis of the applicant's symptoms/disorder </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="The significance of the applicant's LACK of symptoms/mental health disorder(s) ">The significance of the applicant's LACK of symptoms/mental health disorder(s) </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="The significance and prognosis of the applicant's past episodes of suicidal thoughts, attempts, and/or self-harm ">The significance and prognosis of the applicant's past episodes of suicidal thoughts, attempts, and/or self-harm </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="The significance of the applicant's affect or outward presentation ">The significance of the applicant's affect or outward presentation </label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_62" value="Other:">Other:<input class="cst_Other" name="CST_62_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>Medical Evaluation Goals (If Applicable)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please have the medical evaluator: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Assess and document scars and/or other visible physical sequelae attributed to the reported traumas">Assess and document scars and/or other visible physical sequelae attributed to the reported traumas</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Assess for female genital mutilation/cutting (FGM/FGC)">Assess for female genital mutilation/cutting (FGM/FGC)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Assess for hearing impairment (cursory assessment only)">Assess for hearing impairment (cursory assessment only)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Assess for visible damage to eyes (cursory assessment only)">Assess for visible damage to eyes (cursory assessment only)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Assess for dental trauma (cursory assessment only)">Assess for dental trauma (cursory assessment only)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Review past medical records">Review past medical records</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_64" value="Other:">Other:<input class="cst_Other" name="CST_64_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">The applicant reports scars and/or visible physical sequelae in the following areas:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">If known, please list reported types of physical sequelae:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Burns">Burns</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Stab wounds or gouges ">Stab wounds or gouges </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Scars from being sliced or cut">Scars from being sliced or cut</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Permanent/unresolved bone dislocation ">Permanent/unresolved bone dislocation </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Loss of limbs/body parts">Loss of limbs/body parts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Bullet wounds">Bullet wounds</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="FGM">FGM</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="Blows to the head">Blows to the head</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" 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_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">If known, please specify where the reported physical sequelae are located:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Face/Head">Face/Head</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Mouth/Teeth">Mouth/Teeth</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Neck">Neck</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Breasts">Breasts</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Shoulders">Shoulders</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Stomach/Trunk">Stomach/Trunk</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Back">Back</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Arms/Hands">Arms/Hands</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Upper Legs">Upper Legs</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Lower Legs">Lower Legs</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Feet/Ankles">Feet/Ankles</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Genitalia">Genitalia</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_65" value="Other:">Other:<input class="cst_Other" name="CST_65_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>Applicant Information and Demographics (Required)</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_17" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Name_Middle"><i class="fa fa-font"></i><label class="er_fld_label">Middle Name</label><input name="CST_15" type="text" value=""></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_16" type="text" class="er_fld_required"></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 required">Preferred Name</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">A# (if assigned or known)</label><input name="CST_60" type="text" value="" class=""></li></ul><ul class="er_fld_row"><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 required">Applicant's Email Address</label><input name="CST_43" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Home"><i class="fa fa-font"></i><label class="er_fld_label required">Applicant's Phone Number</label><input name="CST_44" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Phone_Other"><i class="fa fa-font"></i><label class="er_fld_label">Any Additional Contact Information (please specify)</label><input name="CST_45" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;" 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_20" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Gender"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Sex and Gender Identity</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Female (Cis)">Female (Cis)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Male (Cis)">Male (Cis)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Trans Female (assigned male at birth)">Trans Female (assigned male at birth)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Trans Male (assigned female at birth)">Trans Male (assigned female at birth)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Gender Neutral (they/them/their)">Gender Neutral (they/them/their)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Non-Binary">Non-Binary</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Genderqueer">Genderqueer</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Gender Fluid">Gender Fluid</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Non-Conforming">Non-Conforming</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Intersex">Intersex</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Rather Not Say">Rather Not Say</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Sexual Orientation</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="LGBTQIA+">LGBTQIA+</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="Rather Not Say">Rather Not Say</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="Straight">Straight</label><label class="er_option"><input class="type_radio" type="radio" name="CST_76" value="Not Known">Not Known</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_76" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_76_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="Country_UNID"><i class="fa fa-font"></i><label class="er_fld_label required">Country of Origin</label><input name="CST_21" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Race"><i class="fa fa-font"></i><label class="er_fld_label required">Race/Ethnicity</label><input name="CST_22" type="text" class="er_fld_required" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Employment"><i class="fa fa-font"></i><label class="er_fld_label required">Employment Status</label><input name="CST_25" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Education"><i class="fa fa-font"></i><label class="er_fld_label required">Education Level</label><input name="CST_30" 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_MaritalStatus"><i class="fa fa-font"></i><label class="er_fld_label required">Legal Marital Status</label><input name="CST_28" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_8"><i class="fa fa-font"></i><label class="er_fld_label required">Current Housing Status</label><input name="CST_29" 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_Religion"><i class="fa fa-font"></i><label class="er_fld_label required">Religion</label><input name="CST_26" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Details?</label><input name="CST_85" 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">Household Information (Required)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Note: we are unable to process your referral without the following information:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the applicant live in Washington State?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_74" 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_74" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_74_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">City of Residence</label><input name="CST_42" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code of Residence</label><input name="CST_82" 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_FamSize"><i class="fa fa-font"></i><label class="er_fld_label required">Household Size (in US)</label><input name="CST_27" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Household Income (in US)</label><input name="CST_84" type="text" class="er_fld_required" value=""></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_warn">Note: annual household income must be at or below 200% of the 2023 federal poverty level: 1 person: $29,160 2 people: $39,440 3 people: $49,720 4 people: $60,000 5 people: $70,280 6 people: $80,560 7 people: $90,840 8 people: $101,120 9+ people: add $10,280 for each additional person</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Seattle Connection</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">SAFE Net is funded in part by a grant from the City of Seattle, and we can only accept non-Seattle referrals under limited circumstances at this time</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Client lives in Seattle">Client lives in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Case Derivative (CD) lives in Seattle">Case Derivative (CD) lives in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Client works in Seattle">Client works in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="CD works in Seattle">CD works in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Client goes to school in Seattle">Client goes to school in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="CD goes to school in Seattle">CD goes to school in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Client volunteers in Seattle">Client volunteers in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="CD volunteers in Seattle">CD volunteers in Seattle</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="Client involved in Seattle community orgs.">Client involved in Seattle community orgs.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="CD involved in Seattle community orgs.">CD involved in Seattle community orgs.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_59" value="No Seattle connection">No Seattle connection</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_59" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_59_Other" type="text"></label></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 required">Zip Code(s) where the above activities take place:</label><input name="CST_83" type="text" class="er_fld_required"></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>Referring Agency (Required)</label><hr></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 required">Your Name</label><input name="CST_46" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Case Connection</label><input name="CST_81" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have We Worked Together Before? (Past Evaluations)</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="No">No</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="Unsure">Unsure</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label></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 required">Representing Attorney's Full Name</label><input name="CST_47" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label required">Law Firm or Organization</label><input name="CST_51" 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%;"><i class="fa fa-font"></i><label class="er_fld_label required">Attorney's Email Address</label><input name="CST_48" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label required">Attorney's Phone Number - able to text and call</label><input name="CST_52" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Paralegal or Assistant's Full Name</label><input name="CST_89" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Para/Asst's Email Address</label><input name="CST_54" type="text" class="" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Para/Asst's Phone Number</label><input name="CST_78" type="text" class="" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Communication Preferences (Note: we do not schedule directly with the applicant)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Email Attorney">Please Email Attorney</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Email Paralegal">Please Email Paralegal</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Text Attorney">Please Text Attorney</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Text Paralegal">Please Text Paralegal</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Call Attorney">Please Call Attorney</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_40" value="Please Call Paralegal">Please Call Paralegal</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_40" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_40_Other" type="text"></label></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 required">Mailing Address (for Affidavit copies)</label><input name="CST_50" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Fax</label><input name="CST_53" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Agency Affiliations and Other Service Needs (Optional)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_8"><i class="fa fa-font"></i><label class="er_fld_label">LDN# </label><input name="CST_10" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_7"><i class="fa fa-font"></i><label class="er_fld_label">NWIRP Legal Server#</label><input name="CST_31" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col4" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Is applicant a patient at Harborview Medical Center?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_33" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_33" value="Other:">Other:<input class="cst_Other" name="CST_33_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_5" er_fld_condfld="CST_11" er_fld_condvals="er_fld_showif_values=Medical+&er_fld_showif_values=Medical+%26+Psychological"><i class="fa fa-font"></i><label class="er_fld_label">If yes, Please List H/U# or Provider Name, if known:</label><input name="CST_34" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Is Applicant Receiving Other Services at RNW / LCSNW?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Counseling">Counseling</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Case Management">Case Management</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Foster Care">Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Torture Treatment">Torture Treatment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Refugee Elder Support">Refugee Elder Support</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Dropout Prevention Program ">Dropout Prevention Program </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Immigration Assistance">Immigration Assistance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="N/A">N/A</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other" name="CST_35_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>Final Signature</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Please sign acknowledging you have filled out this form to the best of your ability.</label><div class="cst_signaturepad"></div><input name="CST_72" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul>
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