Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please complete the form to the best of your ability. **IMPORTANT- READ INSTRUCTIONS BELOW FOR MOBILE DEVICES** If you are filling out the form on a mobile device, position your phone horizontally to complete the form. You must click submit at the bottom once completed. You will receive an automated email response once your application is submitted. If you have any problems with the application, you can email familyhousingapp@umchildrenshome.org.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about us? </label><select name="CST_2" class="er_fld_required er_fld_blank er_fld_width25"><option value="-Not specified-">-Not specified-</option><option value="Wellroot website" selected="">Wellroot website</option><option value="United Way 211">United Way 211</option><option value="Decatur Cooperative Ministries">Decatur Cooperative Ministries</option><option value="Our House">Our House</option><option value="Partner agency">Partner agency</option><option value="Former resident">Former resident</option><option value="Friend or family member">Friend or family member</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">Your first name: </label><input name="CST_4" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Your last name:</label><input name="CST_57" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_DOB"> <i class="fa fa-font"></i><label class="er_fld_label required">Your date of birth:</label><input name="CST_3" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_PersonalPhone"> <i class="fa fa-font"></i><label class="er_fld_label required">Your phone number:</label><input name="CST_8" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">May we leave a voicemail at the phone number listed above?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="No">No</label> <label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_67" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_67_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_PersonalEmail"> <i class="fa fa-font"></i><label class="er_fld_label">Your email address:</label><input name="CST_10" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Gender" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Gender:</label><select name="CST_62" class="er_fld_width25"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option><option value="Non-binary">Non-binary</option></select></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">Race</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="American Indian or Alaska Native">American Indian or Alaska Native</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Asian">Asian</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Black or African American">Black or African American</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Hispanic or Latino">Hispanic or Latino</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_65" value="White">White</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_65" value="Other:">Other:<input class="cst_Other" name="CST_65_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Religion"> <i class="fa fa-font"></i><label class="er_fld_label">Religious affiliation:</label><input name="CST_53" type="text" class="er_fld_width25"></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">Street address of where you currently reside:</label><input name="CST_9" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip code of where you currently reside:</label><input name="CST_60" type="text" class="er_fld_required er_fld_width25"></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">Name of other adult(s) in the household, if applicable:</label><input name="CST_5" type="text" class="er_fld_width25"></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">Relationship of other adult household member (s):</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Spouse">Spouse</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Significant other">Significant other</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Adult son or daughter">Adult son or daughter</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Family member">Family member</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="n/a I am the only adult in the household.">n/a I am the only adult in the household.</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_7" value="Other:">Other:<input class="cst_Other" name="CST_7_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Number of children under 18 in the household:</label><select name="CST_11" class="er_fld_required er_fld_width25"><option value="0">0</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=""></option></select></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">Name & gender of oldest child in the household: </label><input name="CST_12" type="text" class="er_fld_width25"></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">Date of birth of oldest child:</label><input class="cst_datepicker er_fld_width25" name="CST_13" type="text"></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">Name & gender of 2nd oldest child in the household (if applicable):</label><input name="CST_14" type="text" class="er_fld_width25"></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">Date of birth of 2nd oldest child in the household (if applicable):</label><input class="cst_datepicker er_fld_width25" name="CST_15" type="text"></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">Name & gender of 3rd oldest child in the household (if applicable)</label><input name="CST_16" type="text" class="er_fld_width25"></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">Date of birth of 3rd oldest child in the household:</label><input class="cst_datepicker er_fld_width25" name="CST_17" type="text"></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">Name & gender of 4th oldest child in the household (if applicable)</label><input name="CST_19" type="text" value="" class="er_fld_width25"></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">Date of birth of 4th oldest child in the household:</label><input class="cst_datepicker er_fld_width25" name="CST_18" type="text"></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">What grade are your children in, if applicable? List for all children:</label><input name="CST_20" type="text" class="er_fld_width25"></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">What school(s) does your child/children attend?</label><input name="CST_21" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Do all of your children under the age of 18 live with you? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_63" 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_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_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">If no, please explain:</label><input name="CST_64" type="text" class="er_fld_width25"></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">Provide the name and contact information of 2 references, and include your relationship to them:</label><input name="CST_22" type="text" class="er_fld_required er_fld_width25"></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 required">What sources of income do you currently have? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Income from employment">Income from employment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="SSI or SSDI">SSI or SSDI</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Temporary Assistance for Needy Families (TANF)">Temporary Assistance for Needy Families (TANF)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Child Support">Child Support</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Supplemental Nutrition Assistance Program (SNAP)">Supplemental Nutrition Assistance Program (SNAP)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Unemployment">Unemployment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="Workman's compensation">Workman's compensation</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_28" value="None">None</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_28" value="Other:">Other:<input class="cst_Other er_fld_required" 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">For any income you checked above, list the amount of income from each source:</label><input name="CST_66" type="text" class="er_fld_width25"></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">What is your current household monthly income?</label><input name="CST_29" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_Employ_Status"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Indicate your employment status:</label><select name="CST_58" class="er_fld_required er_fld_width25"><option value="-Not specified-" selected="">-Not specified-</option><option value="Not employed" selected="">Not employed</option><option value="Part-time">Part-time</option><option value="Full-time">Full-time</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Employ_Employer"> <i class="fa fa-font"></i><label class="er_fld_label">If you are employed, list your place of employment:</label><input name="CST_50" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If there is another adult in the household, are they employed? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="Yes">Yes</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="No">No</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_32" value="N/A- no other adult household members">N/A- no other adult household members</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_32" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_32_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">List your past 3 places of employment, and include dates of employment:</label><input name="CST_33" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are you in currently in debt?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_34" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_34" 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_34" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_34_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">If you are in debt, what types of debt? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Credit card">Credit card</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Student loans">Student loans</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Past evictions">Past evictions</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Foreclosure">Foreclosure</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Past due utility payments">Past due utility payments</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_35" value="Traffic tickets">Traffic tickets</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other" name="CST_35_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What is your highest level of education completed? </label><select name="CST_36" class="er_fld_required er_fld_width25"><option value="-Not specified- " selected="">-Not specified- </option><option value="Some high school">Some high school</option><option value="High school graduate">High school graduate</option><option value="Associates degree">Associates degree</option><option value="Some college">Some college</option><option value="College graduate">College graduate</option><option value="Post-graduate degree">Post-graduate degree</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">For adult #2 if applicable, what is the highest level of education completed? </label><select name="CST_37" class="er_fld_width25"><option value="-Not specified-" selected="">-Not specified-</option><option value="Some high school">Some high school</option><option value="High School graduate">High School graduate</option><option value="Some college">Some college</option><option value="Associates degree">Associates degree</option><option value="College graduate">College graduate</option><option value="Post graduate degree">Post graduate degree</option></select></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">Please list any physical or mental health concerns of any household members, if applicable: </label><input name="CST_38" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Has anyone in your household had trouble with alcohol or drug use?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_40" value="No">No</label> <label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_40" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_40_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If yes, what, if any, treatment was sought? </label><input name="CST_41" type="text" class="er_fld_width25"></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">Who is your medical insurance provider, if you have insurance?</label><input name="CST_43" type="text" class="er_fld_width25"></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">Describe any previous or current experiences you or your family has had with counseling:</label><input name="CST_42" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Have you ever been homeless before this current episode? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" 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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Have you ever lived in a shelter or transitional housing program? </label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_46" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_46" 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_46" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_46_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">If yes, what program or shelter, and when did you leave the program/shelter? </label><input name="CST_47" type="text" class="er_fld_width25"></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">List your 3 most recent addresses:</label><input name="CST_48" type="text" class="er_fld_required er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What is your primary mode of transportation?</label><select name="CST_49" class="er_fld_required er_fld_width25"><option value="-Not specified-" selected="">-Not specified-</option><option value="Personal vehicle" selected="">Personal vehicle</option><option value="MARTA">MARTA</option><option value="Borrowed vehicle">Borrowed vehicle</option><option value="Rides from friends/family">Rides from friends/family</option><option value="UBER/LYFT">UBER/LYFT</option></select></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">Who do you consider in your support system? What type of support do they provide to you? </label><input name="CST_51" type="text" class="er_fld_width25"></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">What are your family's strengths? </label><input name="CST_52" type="text" class="er_fld_width25"></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">What are your personal goals? </label><input name="CST_23" type="text" class="er_fld_width25"></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">What are your professional goals? </label><input name="CST_24" type="text" class="er_fld_width25"></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">What types of services are you currently receiving, if any? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Mental health counseling">Mental health counseling</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Job readiness/employment services">Job readiness/employment services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Veterans Administration ">Veterans Administration </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Probation or Parole">Probation or Parole</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="DFCS (Family support or family preservation)">DFCS (Family support or family preservation)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="DFCS - TANF/SNAP benefits">DFCS - TANF/SNAP benefits</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Substance abuse treatment">Substance abuse treatment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="Head Start">Head Start</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_55" value="None">None</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_55" value="Other:">Other:<input class="cst_Other" name="CST_55_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">By checking "I agree" below I agree that the information in this application I am submitting is correct to the best of my knowledge. I understand that submitting this application does not guarantee acceptance in the Family Housing Program at Wellroot Family Services. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"></label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_69" value="I agree">I agree</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_69" value="Other:">Other:<input class="cst_Other" name="CST_69_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">Thank you! </div></li></ul>
Submit