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_fontstyle_info">Refugee & Immigrant Services Program Referral Form </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Referral Source</label><select name="CST_13"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Seattle’s Union Gospel Mission">Seattle’s Union Gospel Mission</option><option value="Asylum Evaluation Student Clinic Team">Asylum Evaluation Student Clinic Team</option><option value=""></option></select></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">Client First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Client Middle Name</label><input name="CST_32" type="text"></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">Client Last Name</label><input name="CST_8" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_2" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false" map_to="CC_Gender"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Gender</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Male ">Male </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Female">Female</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_18" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_18_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label">Client's Phone Number</label><input name="CST_3" type="text" class=""></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Can we leave a message? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_4" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_4" 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_4" value="Other:">Other:<input class="cst_Other" name="CST_4_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_EMail"> <i class="fa fa-font"></i><label class="er_fld_label">Client's Email Address</label><input name="CST_9" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Family Size</label><select name="CST_10"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Number of Adults in Family</label><select name="CST_15"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Number of Children under 18 only</label><select name="CST_33"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="Country_UNID"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Country of Origin</label><select name="CST_25"><option value="Afghanistan">Afghanistan</option><option value="Akrotiri">Akrotiri</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antarctica">Antarctica</option><option value="Antigua">Antigua</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Ashmore and Cartier Islands">Ashmore and Cartier Islands</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="Bahamas">Bahamas</option><option value="Bahrain">Bahrain</option><option value="Baker Island">Baker Island</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Bassas Da India">Bassas Da India</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bonaire, Sint Eustatius, and Saba">Bonaire, Sint Eustatius, and Saba</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Bouvert Island">Bouvert Island</option><option value="Brazil">Brazil</option><option value="British Indian Ocean Territory">British Indian Ocean Territory</option><option value="British Virgin Islands">British Virgin Islands</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso (UVolta)">Burkina Faso (UVolta)</option><option value="Burundi">Burundi</option><option value="Cabo Verde">Cabo Verde</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Christmas Island">Christmas Island</option><option value="Clipperton Island">Clipperton Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoro Islands">Comoro Islands</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Coral Sea Islands">Coral Sea Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'lvoire">Cote d'lvoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Curacao">Curacao</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Dem. Rep. Congo">Dem. Rep. Congo</option><option value="Denmark">Denmark</option><option value="Dhekelia">Dhekelia</option><option value="Diego Garcia">Diego Garcia</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="East Timor">East Timor</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Ethiopia">Ethiopia</option><option value="Europa Island">Europa Island</option><option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Guiana">French Guiana</option><option value="French Polynesia">French Polynesia</option><option value="French Southern and Antarctic Lands">French Southern and Antarctic Lands</option><option value="Gabon">Gabon</option><option value="Gambia">Gambia</option><option value="Gaza Strip">Gaza Strip</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Glorioso Islands">Glorioso Islands</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea - Bissau">Guinea - Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Heard Islands and McDonald Islands">Heard Islands and McDonald Islands</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Howland Island">Howland Island</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Ivory Coast">Ivory Coast</option><option value="Jamaica">Jamaica</option><option value="Jan Mayen">Jan Mayen</option><option value="Japan (also Ryukyu Islands - North)">Japan (also Ryukyu Islands - North)</option><option value="Jarvis Island">Jarvis Island</option><option value="Jersey">Jersey</option><option value="Johnston Atoll">Johnston Atoll</option><option value="Jordan">Jordan</option><option value="Juan De Nova Island">Juan De Nova Island</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kingman Reef">Kingman Reef</option><option value="Kiribati">Kiribati</option><option value="Korea, North">Korea, North</option><option value="Korea, Republic of South">Korea, Republic of South</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar (Malagasy Republic)">Madagascar (Malagasy Republic)</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Man, Isle of">Man, Isle of</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Midway Islands">Midway Islands</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar (Burma)">Myanmar (Burma)</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Navassa Island">Navassa Island</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="Netherlands Antilles">Netherlands Antilles</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Norway">Norway</option><option value="Occupied Palestinian Territory">Occupied Palestinian Territory</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Palestine">Palestine</option><option value="Palmyra Atoll">Palmyra Atoll</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paracel Islands">Paracel Islands</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Reunion">Reunion</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Martin">Saint Martin</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Sint Maarten">Sint Maarten</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="South Africa">South Africa</option><option value="South Georgia and South Sandwich Islands">South Georgia and South Sandwich Islands</option><option value="South Sudan">South Sudan</option><option value="Spain">Spain</option><option value="Spratly Islands">Spratly Islands</option><option value="Sri Lanka (Ceylon)">Sri Lanka (Ceylon)</option><option value="Stateless Citizenship">Stateless Citizenship</option><option value="St. Helena">St. Helena</option><option value="St. Kitts and Nevis">St. Kitts and Nevis</option><option value="St. Lucia">St. Lucia</option><option value="St. Pierre and Miquelon">St. Pierre and Miquelon</option><option value="St. Vincent and The Grenadines">St. Vincent and The Grenadines</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Swaziland">Swaziland</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="The Gambia">The Gambia</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tromelin Island">Tromelin Island</option><option value="Trust Territory of the Pacific Islands">Trust Territory of the Pacific Islands</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="Union of Soviet Socialist Republics">Union of Soviet Socialist Republics</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="United States of America">United States of America</option><option value="Unknown">Unknown</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="Virgin Islands">Virgin Islands</option><option value="Wake Island">Wake Island</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Washington Proc Ctr">Washington Proc Ctr</option><option value="West Bank">West Bank</option><option value="Western Sahara">Western Sahara</option><option value="Western Samoa">Western Samoa</option><option value="Yemen">Yemen</option><option value="Yugoslavia">Yugoslavia</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option></select></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">Preferred Language</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: 33.3333%;" map_to="CC_Language_B"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Language</label><input name="CST_19" type="text"></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Is the client proficient in English?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_26" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_26" value="No">No</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_26" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_26_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CustomField_Value_5" style="width: 50%;"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Immigration Status </label><select name="CST_7" class=""><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Asylum Granted">Asylum Granted</option><option value="Asylum Pending">Asylum Pending</option><option value="Afghan Humanitarian Parole">Afghan Humanitarian Parole</option><option value="Ukrainian Humanitarian Parole">Ukrainian Humanitarian Parole</option><option value="Cuban-Haitian Humanitarian Parolee">Cuban-Haitian Humanitarian Parolee</option><option value="DT Parolee">DT Parolee</option><option value="U-Visa">U-Visa</option><option value="T-Visa">T-Visa</option><option value="VAWA">VAWA</option><option value="WOR">WOR</option><option value="CAT">CAT</option><option value="Refugee">Refugee</option><option value="SIJ">SIJ</option><option value="SIV">SIV</option><option value="TPS">TPS</option><option value="Undocumented">Undocumented</option></select></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">Address Line 1</label><input name="CST_20" type="text"></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_21" 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">City</label><input name="CST_22" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Address_State"> <i class="fa fa-caret-down"></i><label class="er_fld_label">State</label><select name="CST_23"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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">Zip Code</label><input name="CST_24" 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>Section Break</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">Reason for Referral</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Housing & Utilities</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_27" value="Rental assistance / eviction prevention">Rental assistance / eviction prevention</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_27" value="Housing navigation (finding affordable units, landlord connections)">Housing navigation (finding affordable units, landlord connections)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_27" value="Utility assistance">Utility assistance</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_27" value="Other:">Other:<input class="cst_Other" name="CST_27_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Employment & Education</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Job search / placement">Job search / placement</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Resume support / training programs">Resume support / training programs</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="English language classes (ESL/ELL)">English language classes (ESL/ELL)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Vocational or skills training">Vocational or skills training</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_28" value="Other:">Other:<input class="cst_Other" name="CST_28_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Health & Wellness</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="Access to primary health care">Access to primary health care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="Mental health counseling / support">Mental health counseling / support</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="Family planning / reproductive health education">Family planning / reproductive health education</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_29" value="Public benefits navigation (Medicaid, Apple Health, SNAP, etc.)">Public benefits navigation (Medicaid, Apple Health, SNAP, etc.)</label><label class="er_option er_option_other"><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><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Legal & Immigration</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Asylum application support">Asylum application support</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Work authorization (EAD) assistance">Work authorization (EAD) assistance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Family reunification / derivative petitions">Family reunification / derivative petitions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_30" value="Immigration attorney referral">Immigration attorney referral</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_30" value="Other:">Other:<input class="cst_Other" name="CST_30_Other" type="text"></label></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">Community & Basic Needs</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_31" value="Food assistance">Food assistance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_31" value="Transportation assistance">Transportation assistance</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_31" value="Childcare resources / school enrollment support">Childcare resources / school enrollment support</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_31" value="Other:">Other:<input class="cst_Other" name="CST_31_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_warn">Please email the signed Release of Information (ROI) to RIMSERVICES@lcsnw.org or attach it at to this form.</div></li></ul>
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