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"> Connected Foster Care Referral for Placement</div></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">Thank you for considering Connected Foster Care Please fill out this referral with as much detailed information as possible and click submit (Low Right Corner). Once we receive your referral, we will check Connected foster homes across the state for possible placement. If you need assistance, please call our on-call number at 501-502-0647 or email our Director, Ryan Ropp ryan.ropp@arkansasfamilies.org </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">Child First Name</label><input name="CST_5" type="text" class="er_fld_required er_fld_desc er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Child Last Name</label><input name="CST_6" type="text" class="er_fld_required er_fld_desc er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 25%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Child Gender</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_7" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_7" value="Female">Female</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_7" value="Other:">Other:<input class="cst_Other er_fld_required" 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%;" map_to="CC_Race"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Race</label><select name="CST_31" class="er_fld_required er_fld_width50"><option value="- Please Select -" selected="">- Please Select -</option><option value="African American" selected="">African American</option><option value="Asian">Asian</option><option value="Hispanic">Hispanic</option><option value="Native American">Native American</option><option value="White/Caucasian">White/Caucasian</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Child DOB</label><input class="cst_datepicker er_fld_width50 er_fld_required" name="CST_32" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 100%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Child Age</label><select name="CST_9" class="er_fld_width50"><option value="- Please Select -" selected="">- Please Select -</option><option value="Less than 12 months">Less than 12 months</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="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="CC_Funding_County"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Referring County</label><select name="CST_10" class="er_fld_required er_fld_width50"><option value="- Please Select -" selected="">- Please Select -</option><option value="Arkansas">Arkansas</option><option value="Ashley">Ashley</option><option value="Baxter">Baxter</option><option value="Benton">Benton</option><option value="Boone">Boone</option><option value="Bradley">Bradley</option><option value="Calhoun">Calhoun</option><option value="Carroll">Carroll</option><option value="Chicot">Chicot</option><option value="Clark">Clark</option><option value="Clay">Clay</option><option value="Cleburne">Cleburne</option><option value="Cleveland">Cleveland</option><option value="Columbia">Columbia</option><option value="Conway">Conway</option><option value="Craighead">Craighead</option><option value="Crawford">Crawford</option><option value="Crittenden">Crittenden</option><option value="Cross">Cross</option><option value="Dallas">Dallas</option><option value="Desha">Desha</option><option value="Drew">Drew</option><option value="Faulkner">Faulkner</option><option value="Franklin">Franklin</option><option value="Fulton">Fulton</option><option value="Garland">Garland</option><option value="Grant">Grant</option><option value="Greene">Greene</option><option value="Hempstead">Hempstead</option><option value="Hot Spring">Hot Spring</option><option value="Howard">Howard</option><option value="Independence">Independence</option><option value="Izard">Izard</option><option value="Jackson">Jackson</option><option value="Jefferson">Jefferson</option><option value="Johnson">Johnson</option><option value="Lafayette">Lafayette</option><option value="Lawrence">Lawrence</option><option value="Lee">Lee</option><option value="Lincoln">Lincoln</option><option value="Little River">Little River</option><option value="Logan">Logan</option><option value="Lonoke">Lonoke</option><option value="Madison">Madison</option><option value="Marion">Marion</option><option value="Miller">Miller</option><option value="Mississippi">Mississippi</option><option value="Monroe">Monroe</option><option value="Montgomery">Montgomery</option><option value="Nevada">Nevada</option><option value="Newton">Newton</option><option value="Ouachita">Ouachita</option><option value="Perry">Perry</option><option value="Phillips">Phillips</option><option value="Pike">Pike</option><option value="Poinsett">Poinsett</option><option value="Polk">Polk</option><option value="Pope">Pope</option><option value="Prairie">Prairie</option><option value="Pulaski">Pulaski</option><option value="Randolph">Randolph</option><option value="Saline">Saline</option><option value="Scott">Scott</option><option value="Searcy">Searcy</option><option value="Sebastian">Sebastian</option><option value="Sevier">Sevier</option><option value="Sharp">Sharp</option><option value="Stone">Stone</option><option value="St. Francis">St. Francis</option><option value="Union">Union</option><option value="Van Buren">Van Buren</option><option value="Washington">Washington</option><option value="White">White</option><option value="Woodruff">Woodruff</option><option value="Yell">Yell</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Your Name (DCFS Worker)</label><input name="CST_3" type="text" class="er_fld_required er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Contact Phone #</label><input name="CST_2" type="text" class="er_fld_required er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_ReferringEmail_Ref" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Contact Email Address</label><input name="CST_11" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><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">If a sibling group, please provide name, gender, and age of siblings</label><textarea name="CST_13" style="width:100%;" class="er_fld_width50"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="CC_Removal_Ref"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date child entered foster care</label><input class="cst_datepicker er_fld_width50" name="CST_25" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Why did the child enter foster care?</label><textarea name="CST_14" style="width:100%;" class="er_fld_width50"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Goal_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label">What is the case goal? (select one)</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Reunification">Reunification</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Adoption">Adoption</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="Kinship Placement">Kinship Placement</label><label class="er_option"><input class="type_radio" type="radio" name="CST_26" value="APPLA">APPLA</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_26" value="Other:">Other:<input class="cst_Other" name="CST_26_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Please list any concerns that may impact placement</label><textarea name="CST_20" style="width:100%;" class="er_fld_width50"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">ON MOBILE DEVICE SCROLL TO THE RIGHT FOR "SUBMIT" BUTTON</div></li></ul>
Submit