Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Name_First"><i class="fa fa-font"></i><label class="er_fld_label">First Name</label><input name="CST_8" type="text" value="" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Name_Last"><i class="fa fa-font"></i><label class="er_fld_label">Last Name</label><input name="CST_9" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Gender"><i class="fa fa-font"></i><label class="er_fld_label">Preferred Pronouns</label><input name="CST_30" type="text" class="er_fld_desc"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Occupation"><i class="fa fa-font"></i><label class="er_fld_label">Credential, Role</label><input name="CST_10" type="text" class="er_fld_desc" value="Staff Attorney"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Has Been an Evaluation Network Client Since....</label><input name="CST_15" type="text" class="er_fld_desc"></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>Legal Service Types</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Employer"><i class="fa fa-font"></i><label class="er_fld_label">Law Office, Employer</label><input name="CST_11" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Law Firm, Agency Service Area</label><input name="CST_26" type="text" class="" value="Washington State"></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">Affiliation Type(s)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="NWIRP Employee (NWHHR and/ ELDN)">NWIRP Employee (NWHHR and/ ELDN)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Colectiva Employee (ELDN)">Colectiva Employee (ELDN)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Entre Hermanos Employee (ELDN)">Entre Hermanos Employee (ELDN)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="KIND Employee (ELDN)">KIND Employee (ELDN)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="ACRS Employee (ELDN)">ACRS Employee (ELDN)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="KIND or NWIRP Affiliated, Pro-Bono ">KIND or NWIRP Affiliated, Pro-Bono </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Other Nonprofit Legal Agency">Other Nonprofit Legal Agency</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Multi-specialty Law firm (for-profit)">Multi-specialty Law firm (for-profit)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Private Practice Law Firm">Private Practice Law Firm</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_desc" type="checkbox" name="CST_13" value="Other:">Other:<input class="cst_Other er_fld_desc" name="CST_13_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 er_fld_noprint">Specific to this Client, Individual. Select or Write In All the Apply. </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">Specialty, Specialities</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Immigration Law">Immigration Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Family Law">Family Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Corporate, Business Law">Corporate, Business Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Criminal Law">Criminal Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Environmental Law">Environmental Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Health Law">Health Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Civil Rights">Civil Rights</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Personal Injury Law">Personal Injury Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Employment Law">Employment Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Real Estate Law">Real Estate Law</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Tax Law">Tax Law</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_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Sub-Specialties</label><input name="CST_27" type="text" class="er_fld_desc"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Language"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Languages Spoken</label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_37" value="English">English</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_37" value="Spanish">Spanish</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_desc" type="checkbox" name="CST_37" value="Other:">Other:<input class="cst_Other er_fld_desc" name="CST_37_Other" type="text"></label></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">Financial Structure (Check All that Apply)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Provides Pro-bono Services">Provides Pro-bono Services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Provides Low-Bono Services">Provides Low-Bono Services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Sliding Scale Costs/Fees">Sliding Scale Costs/Fees</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Special Financing Options Offered">Special Financing Options Offered</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_42" value="Services Provided at Standard (Not Reduced) Cost">Services Provided at Standard (Not Reduced) Cost</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_desc" type="checkbox" name="CST_42" value="Other:">Other:<input class="cst_Other er_fld_desc" name="CST_42_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>Preferred Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Work"><i class="fa fa-font"></i><label class="er_fld_label">Office Phone Number</label><input name="CST_32" type="text" class="er_fld_desc"></li><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">Cell Phone</label><input name="CST_31" type="text" class="er_fld_desc"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"> </label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_34" value="Texting is OK">Texting is OK</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_desc" type="checkbox" name="CST_34" value="Other:">Other:<input class="cst_Other er_fld_desc" name="CST_34_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_EMail"><i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_35" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Fax"><i class="fa fa-font"></i><label class="er_fld_label">Fax Number</label><input name="CST_33" type="text" class="er_fld_desc"></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">Responds Most Readily To....</label> <label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_36" value="Emails">Emails</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_36" value="Phone Calls">Phone Calls</label><label class="er_option"><input class="type_checkbox er_fld_desc" type="checkbox" name="CST_36" value="Texts">Texts</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_desc" type="checkbox" name="CST_36" value="Other:">Other:<input class="cst_Other er_fld_desc" name="CST_36_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>Office Information</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">Office Main Number</label><input name="CST_38" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Website</label><input name="CST_39" type="text"></li><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Able to Host Eval Appointment?</label> <label class="er_option"><input class="type_radio er_fld_desc" type="radio" name="CST_41" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_desc" type="radio" name="CST_41" value="No">No</label><label class="er_option"><input class="type_radio er_fld_desc" type="radio" name="CST_41" value="Maybe">Maybe</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_desc" type="radio" name="CST_41" value="Other:">Other:<input class="cst_Other er_fld_desc" 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_Address_Street_1"><i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_20" type="text" class="er_fld_desc"></li></ul><ul class="er_fld_row"><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_22" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Address_State"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_21" type="text" class="er_fld_desc"></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">Zipcode</label><input name="CST_23" type="text" class="er_fld_desc"></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">County</label><input name="CST_25" type="text" class="er_fld_desc"></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">Directions, Location Notes</label><input name="CST_24" type="text" class="er_fld_desc"></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>Mailing Address (If Different Than Physical Office)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label">Mailing Address</label><input name="CST_16" type="text" class="er_fld_desc"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label">City</label><input name="CST_17" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label">State</label><input name="CST_18" type="text" class="er_fld_desc"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label">Zipcode</label><input name="CST_19" type="text" class="er_fld_desc"></li></ul>
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