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class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"></div></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">Mental Health Provider:</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Credentials</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="LGPC">LGPC</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="LMSW ">LMSW </label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_72" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_72_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">Email Address</label><input name="CST_64" 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: 50%;" draggable="false" map_to="CC_ReferralSource_Ref"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Please Check One of the Following:</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_3" value="Therapist">Therapist</label><label class="er_option"><input class="type_radio" type="radio" name="CST_3" value="Psychiatrist">Psychiatrist</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_3" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_3_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 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">Service</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_63" value="PRP">PRP</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_63" value="Respite">Respite</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_63" value="Therapy">Therapy</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_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_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Client Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">1951i Approved</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_5" value="Yes">Yes</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_5" 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_5" value="Other:">Other:<input class="cst_Other" name="CST_5_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="CC_Name_First"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_6" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Street Address</label><input name="CST_8" 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="CC_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_10" type="text" class="er_fld_required er_fld_width25" value="MD"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_11" 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: 33.3333%;" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label">SSN</label><input name="CST_12" type="text" class="er_fld_width50"></li><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</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_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Gender</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_14" value="Male">Male</label><label class="er_option"><input class="type_radio" type="radio" name="CST_14" value="Female">Female</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_14" value="Other:">Other:<input class="cst_Other" name="CST_14_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Race"><i class="fa fa-circle-o"></i><label class="er_fld_label">Race</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="American Indian or Alaska Native">American Indian or Alaska Native</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Asian">Asian</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Black or African American">Black or African American</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Multi-Racial">Multi-Racial</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</label><label class="er_option"><input class="type_radio" type="radio" name="CST_15" value="White">White</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other" type="radio" name="CST_15" value="Other:">Other:<input class="cst_Other" name="CST_15_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Insurance Provider</label><input name="CST_16" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Insurance #</label><input name="CST_17" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Caretaker Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Caretaker Name</label><input name="CST_18" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_19" type="text"></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 required">Phone Number</label><input name="CST_65" 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">Email Address</label><input name="CST_66" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Household Members</label><textarea name="CST_20" style="width:100%;"></textarea></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>Behavioral Health Diagnoses and Codes</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Behavioral Health Diagnosis 1</label><input name="CST_21" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">BH Diagnosis Code 1</label><input name="CST_22" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Behavioral Health Diagnosis 2</label><input name="CST_23" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">BH Diagnosis Code 2</label><input name="CST_24" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Behavioral Health Diagnosis 3</label><input name="CST_25" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">BH Diagnosis Code 3</label><input name="CST_26" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Behavioral Health Diagnosis 4</label><input name="CST_27" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">BH Diagnosis Code 4</label><input name="CST_28" 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">Behavioral Health Diagnosis 5</label><input name="CST_29" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">BH Diagnosis Code 5</label><input name="CST_30" type="text" value="" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Primary Medical Diagnosis</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style=""> <i class="fa fa-font"></i><label class="er_fld_label">Diagnostic Category 1</label><input name="CST_31" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style=""> <i class="fa fa-font"></i><label class="er_fld_label">Diagnostic Category 2</label><input name="CST_32" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style=""> <i class="fa fa-font"></i><label class="er_fld_label">Diagnostic Category 3</label><input name="CST_33" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1 er_fld_type_radio_col2" style="white-space:normal;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Social Elements Impacting Diagnosis</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="None">None</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Problems with access to health care services">Problems with access to health care services</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Housing Problems">Housing Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Problems related to the social environment">Problems related to the social environment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Educational Problems">Educational Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Problems Related to interaction with legal system/crime">Problems Related to interaction with legal system/crime</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Occupational Problems">Occupational Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Other psychosocial and environmental problems">Other psychosocial and environmental problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Homelessness">Homelessness</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Problems with primary support group">Problems with primary support group</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Financial Problems">Financial Problems</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_34" value="Unknown">Unknown</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_34" value="Other:">Other:<input class="cst_Other" name="CST_34_Other" type="text"></label></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 Diagnosis</label><input class="cst_datepicker" name="CST_35" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Who Diagnosed</label><input name="CST_36" type="text"></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">Current Need for Services</label><textarea name="CST_37" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Mental Health Treatment Provider</label><hr></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">Agency</label><input name="CST_38" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Therapist</label><input name="CST_39" 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">Phone</label><input name="CST_41" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_40" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Medication List</label><textarea name="CST_42" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Compliant with Medication</label><select name="CST_43"><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"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Current Treatment</label><hr></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">Modality and Frequency</label><textarea name="CST_44" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Treatment History</label><hr></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">Hospitalizations, RTF, other agencies, etc.</label><textarea name="CST_45" style="width:100%;"></textarea></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">Fire Setting</label><select name="CST_46"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_48" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain current or past history of fire setting</label><textarea name="CST_47" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Sexual Acting Out</label><select name="CST_48"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_50" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain current or past history of sexual acting out</label><textarea name="CST_49" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Substance Abuse</label><select name="CST_50"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain current or past history of substance abuse</label><textarea name="CST_51" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"> <i class="fa fa-caret-down"></i><label class="er_fld_label">Suicidal or Homicidal Ideation</label><select name="CST_52"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_55" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain current or past history of suicidal or homicidal ideation</label><textarea name="CST_53" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false"> <i class="fa fa-caret-down"></i><label class="er_fld_label">School Problems</label><select name="CST_54"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_57" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain current or past history of school problems</label><textarea name="CST_55" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" er_fld_condvals=""> <i class="fa fa-caret-down"></i><label class="er_fld_label">Family History of Mental Health Issues or Alcohol or Drug Treatment</label><select name="CST_56"><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"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_59" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Explain family history of MH issues or drug or alcohol treatment</label><textarea name="CST_57" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Other Pertinent Information</label><textarea name="CST_58" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Signatures</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Referring Mental Health Provider Signature</label><div class="cst_signaturepad"></div><input name="CST_59" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></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">Date signed</label><input class="cst_datepicker er_fld_width25 er_fld_required" name="CST_60" 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_72" er_fld_condvals="er_fld_showif_values=LGPC&er_fld_showif_values=LMSW+"> <i class="fa fa-font"></i><label class="er_fld_label required">Supervisor Name</label><input name="CST_73" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_72" er_fld_condvals="er_fld_showif_values=LGPC&er_fld_showif_values=LMSW+"> <i class="fa fa-font"></i><label class="er_fld_label required">Supervisor Credentials</label><input name="CST_74" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 100%;" er_fld_condvals="er_fld_showif_values=LGPC&er_fld_showif_values=LMSW+" er_fld_condfld="CST_72"> <i class="fa fa-font"></i><label class="er_fld_label required">Supervisor Email Address</label><input name="CST_71" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature er_fld_showif" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=LGPC&er_fld_showif_values=LMSW+" er_fld_condfld="CST_72"> <i class="fa fa-pencil"></i><label class="er_fld_label">Supervisor Signature</label><div class="cst_signaturepad"></div><input name="CST_69" type="text" field_code="<*ES1>"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" er_fld_condvals="er_fld_showif_values=LGPC&er_fld_showif_values=LMSW+" er_fld_condfld="CST_72"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_width25" name="CST_70" type="text" value="<*ED1>"></li></ul>
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