Online Inquiry
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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">Therapeutic Interventions Inquiry Form</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Today's Date</label><input class="cst_datepicker er_fld_required" name="CST_1" type="text" 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">email Address</label><input name="CST_33" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><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 required">Are you willing to parent a child who identifies as a LGBTQ?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_39" 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_39" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_39_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_39" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If no, please explain.</label><textarea name="CST_40" style="width:100%;" class="er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col3" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you willing to parent a child who identifies as a different race, ethnicity and/or religion?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_41" 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_41" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_41_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_41" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If no, please explain.</label><textarea name="CST_42" style="width:100%;" class="er_fld_blank"></textarea></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">Best Phone Number</label><input name="CST_34" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">When is the best time you can be reached?</label><input name="CST_37" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_3" type="text" value="" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Middle_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Middle Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Street Address</label><input name="CST_30" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_31" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_32" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County of Residence</label><input name="CST_35" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Gender_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Gender</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Pronouns</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="FH_DOB_A"> <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_14" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Race_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Race - Ethnicity</label><input name="CST_16" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Language"> <i class="fa fa-font"></i><label class="er_fld_label required">Preferred Language</label><input name="CST_17" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><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 required">Have you been a Tennessee Resident for more than 3 months?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_20" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_20" 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_20" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_20_Other" type="text"></label> </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 required">Are you a US Citizen or Legal Permanent Resident?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_21" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_21" 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_21" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_21_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: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is There a Second Adult?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_10" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_10" 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_10" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_10_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship Status </label><input name="CST_7" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Name_First_B"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's First Name</label><input name="CST_8" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Name_Middle_B"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Middle Name</label><input name="CST_9" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Name_Last_B"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Last Name</label><input name="CST_11" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Gender_B"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Gender</label><input name="CST_13" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Pronouns</label><input name="CST_12" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_DOB_A"> <i class="fa fa-calendar"></i><label class="er_fld_label">2nd Adult's Date of Birth</label><input class="cst_datepicker er_fld_blank" name="CST_15" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Race_B"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Race - Ethnicity</label><input name="CST_18" type="text" value="" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Language"> <i class="fa fa-font"></i><label class="er_fld_label">2nd Adult's Preferred Language</label><input name="CST_19" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label">2nd Adult - Have you been a Tennessee Resident for more than 3 months?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_22" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_22" value="Other:">Other:<input class="cst_Other" name="CST_22_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif er_fld_type_radio_col2 er_fld_selected" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label"> 2nd Adult - Are you a US Citizen or Legal Permanent Resident?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_23" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_23" value="Other:">Other:<input class="cst_Other" name="CST_23_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">Do you have previous experience as a foster parent?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_27" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_27" 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_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Why do you want to foster parent?</label><textarea name="CST_29" style="width:100%;" class="er_fld_required"></textarea></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"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Please let us know if you are interested in fostering children with any of the following special needs (check all that apply):</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Physical">Physical</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Medical">Medical</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Mental Health">Mental Health</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Behavioral Issues">Behavioral Issues</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="Developmental">Developmental</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_43" value="None">None</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_43" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_43_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How did you hear about us?</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="A TI Current Foster Parent">A TI Current Foster Parent</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="A TI Staff Member">A TI Staff Member</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="Community Event">Community Event</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="Google Search">Google Search</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="Social Media">Social Media</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_38" value="Word of Mouth">Word of Mouth</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_38" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_38_Other" type="text"></label></li></ul>
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