Online Inquiry
Please attach a hard copy of this form below, or reenable the web form.
Click the 'Generate Form' link to pre-populate the form when you are ready.
<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_A" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name (Caregiver A):</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="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name (Caregiver A):</label><input name="CST_10" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_EMail" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address (Caregiver A):</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="FH_Phone_Mobile" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number (Caregiver A):</label><input name="CST_3" 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%;"> <i class="fa fa-font"></i><label class="er_fld_label">First Name (Caregiver B):</label><input name="CST_13" 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">Last Name (Caregiver B):</label><input name="CST_14" 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">Email Address (Caregiver B):</label><input name="CST_15" 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">Phone number (Caregiver B):</label><input name="CST_16" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Address_City" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City:</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_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"></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">Preferred response:</label><select name="CST_5"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Email">Email</option><option value="Phone">Phone</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_ReferralSource" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">How did you hear about Youthnet?</label><input name="CST_6" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_selected" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">At this time, I am/We are interested in providing care for the following age range:</label><textarea name="CST_17" style="width:100%;" class="er_fld_required">(e.g. Ages 6-18)</textarea></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">I am/We are interested in providing the following type of care (select all the apply): </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Traditional Foster Care">Traditional Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Therapeutic Foster Care (or "Behavioral Rehabilitation Services (BRS)")">Therapeutic Foster Care (or "Behavioral Rehabilitation Services (BRS)")</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Respite">Respite</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Relative Care (or "Kinship")">Relative Care (or "Kinship")</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Extended Foster Care">Extended Foster Care</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_18" value="Adoption from Foster Care">Adoption from Foster Care</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_18" value="Other:">Other:<input class="cst_Other" name="CST_18_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label"> I/We would consider providing care and support to children who may have the following needs/circumstances (select all the apply): </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Trauma History">Trauma History</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Mental Health Diagnoses ">Mental Health Diagnoses </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Black, Indigenous, or People of Color (BIPOC)">Black, Indigenous, or People of Color (BIPOC)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="LGBTQIA+ ">LGBTQIA+ </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Medical Needs">Medical Needs</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Substance Exposure">Substance Exposure</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Behavioral Needs ">Behavioral Needs </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Autism">Autism</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Learning Disability">Learning Disability</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Teen Parent">Teen Parent</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_19" value="Other:">Other:<input class="cst_Other" name="CST_19_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" map_to="FH_Inquiry_Comments" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Our Recruitment Specialist, Holland, will reach out to you within 24 hours Monday-Friday. If you have any initial questions about foster care, please feel welcome to include these here:</label><textarea name="CST_9" style="width:100%;"></textarea></li></ul>
Submit