Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">Submit a Referral / Enviar una referencia:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label">Your name/nombre:</label><input name="CST_1" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferralSource_Ref"> <i class="fa fa-font"></i><label class="er_fld_label">Referrer Agency/Agencia de Referencia:</label><input name="CST_2" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number of Referrer (if different)/Número de teléfono del referente (Si es Diferente):</label><input name="CST_3" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label">Email of Referrer (if different):</label><input name="CST_4" type="text" class="er_fld_width75"></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">First Name of person who is being referred (if different)/Primer nombre de la persona referida (Si es Diferente):</label><input name="CST_5" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label">Last name of person who is being referred (if different)/ Apellido de persona a la que se refiere (Si es Diferente):</label><input name="CST_13" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_PersonalPhone"> <i class="fa fa-font"></i><label class="er_fld_label">Phone number of person being referred/Número de teléfono de la persona referida:</label><input name="CST_11" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label">DOB of person being referred/Fecha de Nacimiento de la persona a la que se refiere:</label><input class="cst_datepicker er_fld_width75" name="CST_7" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_PrimaryLanguage"> <i class="fa fa-font"></i><label class="er_fld_label">Primary language spoken in home of referred/Idioma principal hablado en el hogar del referido:</label><input name="CST_8" type="text" class="er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-font"></i><label class="er_fld_label">Reason for referral/Motivo de la recomendación:</label><input name="CST_9" type="text" class="er_fld_width75"></li></ul>
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