Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Inner Peace Homes Inquiry Form</label><hr></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 er_fld_fontstyle_info">Section 1: Applicant Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Parent A</label><hr></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" 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">Middle Name:</label><input name="CST_4" type="text"></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_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Address Line 1: </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_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Address Line 2:</label><input name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City:</label><input name="CST_18" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State:</label><input name="CST_19" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code:</label><input name="CST_20" type="text" class="er_fld_required"></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">What is your preferred method of contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_21" value="Email">Email</label><label class="er_option"><input class="type_radio" type="radio" name="CST_21" value="Phone">Phone</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_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Best Number to Reach You At:</label><input name="CST_22" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Email Address:</label><input name="CST_23" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Parent B (If Applicable)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_B"> <i class="fa fa-font"></i><label class="er_fld_label">First Name:</label><input name="CST_6" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Middle_B"> <i class="fa fa-font"></i><label class="er_fld_label">Middle Name:</label><input name="CST_7" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_B"> <i class="fa fa-font"></i><label class="er_fld_label">Last Name:</label><input name="CST_8" type="text" class=""></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">What is your preferred method of contact?</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_29" value="Email">Email</label><label class="er_option"><input class="type_radio" type="radio" name="CST_29" value="Phone">Phone</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_29" value="Other:">Other:<input class="cst_Other" name="CST_29_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Mobile"> <i class="fa fa-font"></i><label class="er_fld_label">Best Number to Reach You At:</label><input name="CST_14" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail_2"> <i class="fa fa-font"></i><label class="er_fld_label">Primary Email Address:</label><input name="CST_15" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Marital Status</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;" map_to="FH_MaritalStatus"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What is your marital status?</label><select name="CST_30" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Single" selected="">Single</option><option value="Married">Married</option><option value="Widowed">Widowed</option><option value="Divorced">Divorced</option><option value=""></option></select></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 er_fld_fontstyle_info">Section 2: Household Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Interested In:</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_10" value="Foster Care">Foster Care</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_10" value="Foster to Adopt">Foster to Adopt</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_10" value="Adoption">Adoption</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_10" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_10_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">Are you at least 18 years old?</label><select name="CST_9" class="er_fld_required"><option value="- Not Specified - ">- Not Specified - </option><option value="Yes" selected="">Yes</option><option value="No">No</option></select></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">Section 3: Interview Questions</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;" map_to="FH_Inquiry_How_Referred"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How were you referred to our program?</label><textarea name="CST_31" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;" map_to="FH_Inquiry_Why_Parents"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Why do you want to be foster/adoptive parents?</label><textarea name="CST_32" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How many children would you be willing to consider? What age ranges?</label><textarea name="CST_33" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What experience do you have with children? Any experience with children with specials needs? Previous adoptive/foster care/day care license? (if yes: Provide agency name, if under special evaluation, reason closed, current placements, capacity) (if no: Have you ever applied or inquired about a foster care license before?)</label><textarea name="CST_34" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Who else resides in the home? (name, age, gender, relationship) If you have children: Do any of the children living in the home have special needs?</label><textarea name="CST_35" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Will all household members be able to pass a criminal background check and central registry check?</label><select name="CST_37" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style=""><i class="fa fa-caret-down"></i><label class="er_fld_label required">Have any of the household members resided in another state within the last 5 years?</label><select name="CST_38" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row" id="er_row_last"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Other comments/details:</label><textarea name="CST_39" style="width:100%;"></textarea></li></ul>
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