{"id":33,"date":"2016-11-06T11:39:43","date_gmt":"2016-11-06T16:39:43","guid":{"rendered":"https:\/\/cdacforms.com\/?page_id=33"},"modified":"2017-08-23T08:17:52","modified_gmt":"2017-08-23T13:17:52","slug":"parent-for-prevention-referral-form","status":"publish","type":"page","link":"https:\/\/cdacforms.com\/index.php\/parent-for-prevention-referral-form\/","title":{"rendered":""},"content":{"rendered":"<body><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Parenting for Prevention - Referral Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/index.php\/wp-json\/wp\/v2\/pages\/33' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_26\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_26'>Date of Referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_5_26' type='text' value='06\/24\/2026' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_26_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_26' class='gform_hidden' value='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Please indicate which parenting program(s) client is being referred to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_1'>\n\t\t\t<li class='gchoice gchoice_5_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='Incredible Years Baby Group: Birth-12 months (baby attends with parent)(8 sessions\/meets weekly)**'  id='choice_5_1_0'    \/>\n\t\t\t\t<label for='choice_5_1_0' id='label_5_1_0' class='gform-field-label gform-field-label--type-inline'>Incredible Years Baby Group: Birth-12 months (baby attends with parent)(8 sessions\/meets weekly)**<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='Incredible Years for parents of young children (18 mo.-8 yrs.) (parents only)(10 sessions\/meets weekly)'  id='choice_5_1_1'    \/>\n\t\t\t\t<label for='choice_5_1_1' id='label_5_1_1' class='gform-field-label gform-field-label--type-inline'>Incredible Years for parents of young children (18 mo.-8 yrs.) (parents only)(10 sessions\/meets weekly)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_1_2'>\n\t\t\t\t<input name='input_1' type='radio' value='Parents of Teens: for parents of pre-teens\/teens:'  id='choice_5_1_2'    \/>\n\t\t\t\t<label for='choice_5_1_2' id='label_5_1_2' class='gform-field-label gform-field-label--type-inline'>Parents of Teens: for parents of pre-teens\/teens:<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_2\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_2'>Please indicate who will bringing the baby to group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_5_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_27\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_27'>Phone for Person Bringing baby to group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_5_27' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_28\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'>Email for Person Bringing baby to group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_28' id='input_5_28' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent(s)\/Guardians being referred:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_3'>\n                            \n                            <span id='input_5_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_5_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_5\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'>Phone 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_5_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent or Guardian 2<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_4'>\n                            \n                            <span id='input_5_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_5_4_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_5_4_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_25\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_25'>Phone 2<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_5_25' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_6\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_5_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_6_1' id='input_5_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_5_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_6_2' id='input_5_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_5_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_6_3' id='input_5_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_6_4_container' >\n                                        <select name='input_6.4' id='input_5_6_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' selected='selected'>Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_6_4' id='input_5_6_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_5_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_6_5' id='input_5_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_5_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_7\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_5_7' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Preferred Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_5_8' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Text' >Text<\/option><option value='Call' >Call<\/option><option value='Email' >Email<\/option><\/select><\/div><\/li><li id=\"field_5_9\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Children Info<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_9'>Select the + to add additional children<\/div><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_9_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_9_col_2' class='gfield_list_col_even' \/><col id='gfield_list_9_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_9_col_4' class='gfield_list_col_even' \/><col id='gfield_list_9_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_9_col_6' class='gfield_list_col_even' \/><col id='gfield_list_9_col_7' class='gfield_list_col_odd' \/><col id='gfield_list_9_col_8' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">First Name<\/th><th scope=\"col\">Last Name<\/th><th scope=\"col\">Gender<\/th><th scope=\"col\">D.O.B<\/th><th scope=\"col\">Age<\/th><th scope=\"col\">Special Concerns<\/th><th scope=\"col\">Child in Home (yes or no)<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_9_cell1' data-label='First Name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='First Name, Row 1' data-aria-label-template='First Name, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell2' data-label='Last Name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='Last Name, Row 1' data-aria-label-template='Last Name, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell3' data-label='Gender'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='Gender, Row 1' data-aria-label-template='Gender, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell4' data-label='D.O.B'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='D.O.B, Row 1' data-aria-label-template='D.O.B, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell5' data-label='Age'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='Age, Row 1' data-aria-label-template='Age, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell6' data-label='Special Concerns'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='Special Concerns, Row 1' data-aria-label-template='Special Concerns, Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_9_cell7' data-label='Child in Home (yes or no)'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_9\" aria-label='Child in Home (yes or no), Row 1' data-aria-label-template='Child in Home (yes or no), Row {0}' type='text' name='input_9[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)'><img src='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style=\"visibility:hidden;\"><img src='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'>Reason for Referral to Parenting:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_5_10' class='textarea medium'   maxlength='1000'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Referral Source<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_12'>\n\t\t\t<li class='gchoice gchoice_5_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='DCF'  id='choice_5_12_0'    \/>\n\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>DCF<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='FFN'  id='choice_5_12_1'    \/>\n\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>FFN<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='gf_other_choice'  id='choice_5_12_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_5_12_other' name='input_12_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_13'>\n                            \n                            <span id='input_5_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_5_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_5_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'>Referral Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_5_14' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_15\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_5_15' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_16\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'>Voluntary<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_5_16' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' >NA<\/option><\/select><\/div><\/li><li id=\"field_5_18\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_18'>Court Ordered<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_5_18' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' >NA<\/option><\/select><\/div><\/li><li id=\"field_5_19\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'>In home non-judicial<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_5_19' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' >NA<\/option><\/select><\/div><\/li><li id=\"field_5_20\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_20'>Out of home judicial<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_5_20' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' >NA<\/option><\/select><\/div><\/li><li id=\"field_5_21\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_21'>Child(ren) are sheltered<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_5_21' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' >NA<\/option><\/select><\/div><\/li><li id=\"field_5_22\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'>Client is WFIS client<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_5_22' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='NA' selected='selected'>NA<\/option><\/select><\/div><\/li><li id=\"field_5_23\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Case Manager<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_23'>\n                            \n                            <span id='input_5_23_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_23.3' id='input_5_23_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_23_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_23_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_23.6' id='input_5_23_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_23_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_24\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_24'>Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_5_24' class='textarea medium'   maxlength='500'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='eNL8eoMgZnJRkh8mUn051rLFPH5vXhNiWk5Wb\/+oUw15w8F2iNHc1kM+UNGtjWY4RbBdaK3jaYn3Xx5fXJdZRV4T17d1mZLNQx061ZWtjoFtla4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='WyJbXSIsIjIxNDViYjM4Zjg3ODRjNGMyM2E4NWQ2YWE2ZWI2M2IwIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"41\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() 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