{"id":3476,"date":"2021-02-14T15:21:48","date_gmt":"2021-02-14T22:21:48","guid":{"rendered":"https:\/\/raisingspecialkids.net\/?page_id=3476"},"modified":"2021-02-14T15:21:50","modified_gmt":"2021-02-14T22:21:50","slug":"refiera-a-una-familia","status":"publish","type":"page","link":"https:\/\/raisingspecialkids.net\/es\/refiera-a-una-familia\/","title":{"rendered":"Refiera a una familia"},"content":{"rendered":"<style>.wForm form{text-align: left;}<\/style><!-- FORM: HEAD SECTION -->\n    <meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n    <meta name=\"referrer\" content=\"no-referrer-when-downgrade\">\n    <!-- THIS SCRIPT NEEDS TO BE LOADED FIRST BEFORE wforms.js -->\n    <script type=\"text\/javascript\" data-for=\"FA__DOMContentLoadedEventDispatch\" src=\"https:\/\/www.tfaforms.com\/js\/FA__DOMContentLoadedEventDispatcher.js\" defer><\/script>\n                    <style>\n                    .captcha {\n                        padding-bottom: 1em 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label[id^=\"tfa_3384[\"],\n                *[id^=\"tfa_3384[\"][id$=\"-L\"] {\n                    height: auto !important;\n                }\n            <\/style><div class=\"\"><div class=\"wForm\" id=\"5157846-WRPR\" data-language=\"en_US\" dir=\"ltr\">\n<div class=\"codesection\" id=\"code-5157846\"><script type=\"text\/javascript\">\nfunction googleTranslateElementInit() {\nnew google.translate.TranslateElement({pageLanguage: 'en'}, 'google_translate_element');\n}\n<\/script>\n<script type=\"text\/javascript\" src=\"\/\/translate.google.com\/translate_a\/element.js?cb=googleTranslateElementInit\"><\/script><\/div>\n<h3 class=\"wFormTitle\" data-testid=\"form-title\" id=\"5157846-T\"><b>Family Referral Form<\/b><\/h3>\n<form method=\"post\" action=\"https:\/\/www.tfaforms.com\/api_v2\/rest\/workflow\/processor\" class=\"hintsBelow labelsAbove\" id=\"5157846\">\n<div class=\"htmlSection\" id=\"tfa_3451\"><div class=\"htmlContent\" id=\"tfa_3451-HTML\">Choose a language to translate this form.<br><div id=\"google_translate_element\"><\/div><\/div><\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3208-D\">\n<label id=\"tfa_3208-L\" class=\"label preField reqMark\" for=\"tfa_3208\">Please select one of the following:<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3208\" name=\"tfa_3208\" title=\"Please select one of the following:\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3209\" id=\"tfa_3209\" data-conditionals=\"#tfa_2820,#tfa_3457\" class=\"\">I am a professional.<\/option>\n<option value=\"tfa_3236\" id=\"tfa_3236\" data-conditionals=\"#tfa_3389,#tfa_5,#submit_button\" class=\"\">I am a parent\/family member.<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3457-D\">\n<label id=\"tfa_3457-L\" class=\"label preField \" for=\"tfa_3457\">Are you a behavioral health professional hoping to refer a family to our Positive Family Coaching (PFC) program?&nbsp;<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3457\" name=\"tfa_3457\" data-condition=\"`#tfa_3209`\" title=\"Are you a behavioral health professional hoping to refer a family to our Positive Family Coaching (PFC) program? \" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3458\" id=\"tfa_3458\" data-conditionals=\"#tfa_5,#submit_button,#tfa_2819\" class=\"\">No<\/option>\n<option value=\"tfa_3459\" id=\"tfa_3459\" data-conditionals=\"#tfa_3456\" class=\"\">Yes<\/option><\/select><\/div>\n<\/div>\n<div id=\"tfa_3456\" class=\"section group\" data-condition=\"`#tfa_3459`\"><div class=\"htmlSection\" id=\"tfa_3453\"><div class=\"htmlContent\" id=\"tfa_3453-HTML\"><b>Instead of using this form, please email the referral directly to <a target=\"_blank\" href=\"mailto:pfcreferrals@encirclefamilies.org\">pfcreferrals@encirclefamilies.org<\/a> so we can support the family as quickly and smoothly as possible. Thank you for referring families to our PFC program!<\/b><\/div><\/div><\/div>\n<fieldset id=\"tfa_2819\" class=\"section\" data-condition=\"`#tfa_3458`\">\n<legend id=\"tfa_2819-L\">Professional Information<\/legend>\n<div id=\"tfa_2820\" class=\"section inline group\" data-condition=\"`#tfa_3209`\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2883-D\">\n<label id=\"tfa_2883-L\" class=\"label preField \" for=\"tfa_2883\">Your First Name<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2883\" name=\"tfa_2883\" value=\"\" maxlength=\"40\" title=\"Your First Name\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3235-D\">\n<label id=\"tfa_3235-L\" class=\"label preField \" for=\"tfa_3235\">Your Last Name<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3235\" name=\"tfa_3235\" value=\"\" maxlength=\"80\" title=\"Your Last Name\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3201-D\">\n<label id=\"tfa_3201-L\" class=\"label preField \" for=\"tfa_3201\">I am a:<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3201\" name=\"tfa_3201\" title=\"I am a:\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3202\" id=\"tfa_3202\" class=\"\">DDD Staff<\/option>\n<option value=\"tfa_3203\" id=\"tfa_3203\" class=\"\">AzEIP Staff<\/option>\n<option value=\"tfa_3381\" id=\"tfa_3381\" class=\"\">AZ Newborn Screening Staff<\/option>\n<option value=\"tfa_3204\" id=\"tfa_3204\" class=\"\">Behavioral Health Professional<\/option>\n<option value=\"tfa_3205\" id=\"tfa_3205\" class=\"\">Medical Professional<\/option>\n<option value=\"tfa_3206\" id=\"tfa_3206\" class=\"\">Education Professional<\/option>\n<option value=\"tfa_3207\" id=\"tfa_3207\" class=\"\">Other Professional<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3200-D\">\n<label id=\"tfa_3200-L\" class=\"label preField \" for=\"tfa_3200\">Agency<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3200\" name=\"tfa_3200\" value=\"\" title=\"Agency\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2890-D\">\n<label id=\"tfa_2890-L\" class=\"label preField \" for=\"tfa_2890\">Email<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2890\" name=\"tfa_2890\" value=\"\" title=\"Email\" class=\"validate-email\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2884-D\">\n<label id=\"tfa_2884-L\" class=\"label preField \" for=\"tfa_2884\">Phone<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2884\" name=\"tfa_2884\" value=\"\" placeholder=\"###-###-####\" autoformat=\"(###) ###-####\" title=\"Phone\" class=\"\"><\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"tfa_5\" class=\"section\" data-condition=\"`#tfa_3458` OR `#tfa_3236`\">\n<legend id=\"tfa_5-L\">Family Information<\/legend>\n<div id=\"tfa_193\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_1-D\">\n<label id=\"tfa_1-L\" class=\"label preField reqMark\" for=\"tfa_1\">Parent\/Caregiver's First Name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_1\" name=\"tfa_1\" value=\"\" maxlength=\"40\" title=\"Parent\/Caregiver's First Name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2-D\">\n<label id=\"tfa_2-L\" class=\"label preField reqMark\" for=\"tfa_2\">Parent\/Caregiver's&nbsp;Last Name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2\" name=\"tfa_2\" value=\"\" maxlength=\"80\" title=\"Parent\/Caregiver's Last Name\" class=\"required\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3362\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3354-D\">\n<label id=\"tfa_3354-L\" class=\"label preField \" for=\"tfa_3354\">Chosen Pronouns<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3354\" name=\"tfa_3354\" title=\"Chosen Pronouns\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3355\" id=\"tfa_3355\" class=\"\">She\/Her<\/option>\n<option value=\"tfa_3356\" id=\"tfa_3356\" class=\"\">He\/Him<\/option>\n<option value=\"tfa_3357\" id=\"tfa_3357\" class=\"\">They\/Them<\/option>\n<option value=\"tfa_3358\" id=\"tfa_3358\" class=\"\">She\/They<\/option>\n<option value=\"tfa_3359\" id=\"tfa_3359\" class=\"\">He\/They<\/option>\n<option value=\"tfa_3360\" id=\"tfa_3360\" data-conditionals=\"#tfa_3361\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3361-D\">\n<label id=\"tfa_3361-L\" class=\"label preField \" for=\"tfa_3361\">Other Pronouns<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3361\" name=\"tfa_3361\" value=\"\" data-condition=\"`#tfa_3360`\" title=\"Other Pronouns\" class=\"\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3382\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2190-D\">\n<label id=\"tfa_2190-L\" class=\"label preField \" for=\"tfa_2190\">Primary Language<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_2190\" name=\"tfa_2190\" title=\"Primary Language\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_2192\" id=\"tfa_2192\" class=\"\">English<\/option>\n<option value=\"tfa_2196\" id=\"tfa_2196\" class=\"\">Spanish<\/option>\n<option value=\"tfa_2198\" id=\"tfa_2198\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3238-D\">\n<label id=\"tfa_3238-L\" class=\"label preField \" for=\"tfa_3238\">Preferred Method of Contact<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3238\" name=\"tfa_3238\" title=\"Preferred Method of Contact\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3239\" id=\"tfa_3239\" class=\"\">Phone<\/option>\n<option value=\"tfa_3240\" id=\"tfa_3240\" class=\"\">Text<\/option>\n<option value=\"tfa_3380\" id=\"tfa_3380\" class=\"\">Email<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3172\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3233-D\">\n<label id=\"tfa_3233-L\" class=\"label preField reqMark\" for=\"tfa_3233\">Phone<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_3233\" name=\"tfa_3233\" value=\"\" autoformat=\"(###) ###-####\" title=\"Phone\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3-D\">\n<label id=\"tfa_3-L\" class=\"label preField reqMark\" for=\"tfa_3\">Email<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_3\" name=\"tfa_3\" value=\"\" title=\"Email\" class=\"validate-email required\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3351\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3250-D\">\n<label id=\"tfa_3250-L\" class=\"label preField reqMark\" for=\"tfa_3250\">City<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3250\" name=\"tfa_3250\" title=\"City\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3251\" id=\"tfa_3251\" class=\"\">Anthem<\/option>\n<option value=\"tfa_3252\" id=\"tfa_3252\" class=\"\">Apache Junction<\/option>\n<option value=\"tfa_3253\" id=\"tfa_3253\" class=\"\">Arizona City<\/option>\n<option value=\"tfa_3254\" id=\"tfa_3254\" class=\"\">Avondale<\/option>\n<option value=\"tfa_3255\" id=\"tfa_3255\" class=\"\">Avra Valley<\/option>\n<option value=\"tfa_3256\" id=\"tfa_3256\" class=\"\">Benson<\/option>\n<option value=\"tfa_3257\" id=\"tfa_3257\" class=\"\">Bisbee<\/option>\n<option value=\"tfa_3258\" id=\"tfa_3258\" class=\"\">Buckeye<\/option>\n<option value=\"tfa_3259\" id=\"tfa_3259\" class=\"\">Bullhead City<\/option>\n<option value=\"tfa_3260\" id=\"tfa_3260\" class=\"\">Camp Verde<\/option>\n<option value=\"tfa_3261\" id=\"tfa_3261\" class=\"\">Casa Grande<\/option>\n<option value=\"tfa_3262\" id=\"tfa_3262\" class=\"\">Casas Adobes<\/option>\n<option value=\"tfa_3263\" id=\"tfa_3263\" class=\"\">Catalina<\/option>\n<option value=\"tfa_3264\" id=\"tfa_3264\" class=\"\">Catalina Foothills<\/option>\n<option value=\"tfa_3265\" id=\"tfa_3265\" class=\"\">Cave Creek<\/option>\n<option value=\"tfa_3266\" id=\"tfa_3266\" class=\"\">Chandler<\/option>\n<option value=\"tfa_3267\" id=\"tfa_3267\" class=\"\">Chinle<\/option>\n<option value=\"tfa_3268\" id=\"tfa_3268\" class=\"\">Chino Valley<\/option>\n<option value=\"tfa_3269\" id=\"tfa_3269\" class=\"\">Citrus Park<\/option>\n<option value=\"tfa_3270\" id=\"tfa_3270\" class=\"\">Colorado City<\/option>\n<option value=\"tfa_3271\" id=\"tfa_3271\" class=\"\">Coolidge<\/option>\n<option value=\"tfa_3272\" id=\"tfa_3272\" class=\"\">Corona de Tucson<\/option>\n<option value=\"tfa_3273\" id=\"tfa_3273\" class=\"\">Cottonwood city<\/option>\n<option value=\"tfa_3274\" id=\"tfa_3274\" class=\"\">Doney Park<\/option>\n<option value=\"tfa_3275\" id=\"tfa_3275\" class=\"\">Douglas<\/option>\n<option value=\"tfa_3276\" id=\"tfa_3276\" class=\"\">Drexel Heights<\/option>\n<option value=\"tfa_3277\" id=\"tfa_3277\" class=\"\">Eagar<\/option>\n<option value=\"tfa_3278\" id=\"tfa_3278\" class=\"\">El Mirage<\/option>\n<option value=\"tfa_3279\" id=\"tfa_3279\" class=\"\">Eloy<\/option>\n<option value=\"tfa_3280\" id=\"tfa_3280\" class=\"\">Flagstaff<\/option>\n<option value=\"tfa_3281\" id=\"tfa_3281\" class=\"\">Florence<\/option>\n<option value=\"tfa_3282\" id=\"tfa_3282\" class=\"\">Flowing Wells<\/option>\n<option value=\"tfa_3283\" id=\"tfa_3283\" class=\"\">Fort Mohave<\/option>\n<option value=\"tfa_3284\" id=\"tfa_3284\" class=\"\">Fortuna Foothills<\/option>\n<option value=\"tfa_3285\" id=\"tfa_3285\" class=\"\">Fountain Hills<\/option>\n<option value=\"tfa_3286\" id=\"tfa_3286\" class=\"\">Gilbert<\/option>\n<option value=\"tfa_3287\" id=\"tfa_3287\" class=\"\">Glendale<\/option>\n<option value=\"tfa_3288\" id=\"tfa_3288\" class=\"\">Globe<\/option>\n<option value=\"tfa_3289\" id=\"tfa_3289\" class=\"\">Gold Canyon<\/option>\n<option value=\"tfa_3290\" id=\"tfa_3290\" class=\"\">Golden Valley<\/option>\n<option value=\"tfa_3291\" id=\"tfa_3291\" class=\"\">Goodyear<\/option>\n<option value=\"tfa_3292\" id=\"tfa_3292\" class=\"\">Green Valley<\/option>\n<option value=\"tfa_3293\" id=\"tfa_3293\" class=\"\">Guadalupe<\/option>\n<option value=\"tfa_3294\" id=\"tfa_3294\" class=\"\">Holbrook<\/option>\n<option value=\"tfa_3295\" id=\"tfa_3295\" class=\"\">Kayenta<\/option>\n<option value=\"tfa_3296\" id=\"tfa_3296\" class=\"\">Kingman<\/option>\n<option value=\"tfa_3297\" id=\"tfa_3297\" class=\"\">Lake Havasu City<\/option>\n<option value=\"tfa_3298\" id=\"tfa_3298\" class=\"\">Litchfield Park<\/option>\n<option value=\"tfa_3299\" id=\"tfa_3299\" class=\"\">Marana<\/option>\n<option value=\"tfa_3300\" id=\"tfa_3300\" class=\"\">Maricopa<\/option>\n<option value=\"tfa_3301\" id=\"tfa_3301\" class=\"\">Mesa<\/option>\n<option value=\"tfa_3302\" id=\"tfa_3302\" class=\"\">New Kingman-Butler<\/option>\n<option value=\"tfa_3303\" id=\"tfa_3303\" class=\"\">New River<\/option>\n<option value=\"tfa_3304\" id=\"tfa_3304\" class=\"\">Nogales<\/option>\n<option value=\"tfa_3305\" id=\"tfa_3305\" class=\"\">Oro Valley<\/option>\n<option value=\"tfa_3306\" id=\"tfa_3306\" class=\"\">Page<\/option>\n<option value=\"tfa_3307\" id=\"tfa_3307\" class=\"\">Paradise Valley<\/option>\n<option value=\"tfa_3308\" id=\"tfa_3308\" class=\"\">Paulden<\/option>\n<option value=\"tfa_3309\" id=\"tfa_3309\" class=\"\">Payson<\/option>\n<option value=\"tfa_3310\" id=\"tfa_3310\" class=\"\">Peoria<\/option>\n<option value=\"tfa_3311\" id=\"tfa_3311\" class=\"\">Phoenix<\/option>\n<option value=\"tfa_3312\" id=\"tfa_3312\" class=\"\">Picture Rocks<\/option>\n<option value=\"tfa_3313\" id=\"tfa_3313\" class=\"\">Prescott<\/option>\n<option value=\"tfa_3314\" id=\"tfa_3314\" class=\"\">Prescott Valley<\/option>\n<option value=\"tfa_3315\" id=\"tfa_3315\" class=\"\">Queen Creek<\/option>\n<option value=\"tfa_3316\" id=\"tfa_3316\" class=\"\">Rincon Valley<\/option>\n<option value=\"tfa_3317\" id=\"tfa_3317\" class=\"\">Rio Rico<\/option>\n<option value=\"tfa_3318\" id=\"tfa_3318\" class=\"\">Saddlebrooke<\/option>\n<option value=\"tfa_3319\" id=\"tfa_3319\" class=\"\">Safford<\/option>\n<option value=\"tfa_3320\" id=\"tfa_3320\" class=\"\">Sahuarita<\/option>\n<option value=\"tfa_3321\" id=\"tfa_3321\" class=\"\">San Luis<\/option>\n<option value=\"tfa_3322\" id=\"tfa_3322\" class=\"\">San Tan Valley<\/option>\n<option value=\"tfa_3323\" id=\"tfa_3323\" class=\"\">Scottsdale<\/option>\n<option value=\"tfa_3324\" id=\"tfa_3324\" class=\"\">Sedona<\/option>\n<option value=\"tfa_3325\" id=\"tfa_3325\" class=\"\">Show Low<\/option>\n<option value=\"tfa_3326\" id=\"tfa_3326\" class=\"\">Sierra Vista<\/option>\n<option value=\"tfa_3327\" id=\"tfa_3327\" class=\"\">Sierra Vista Southeast<\/option>\n<option value=\"tfa_3328\" id=\"tfa_3328\" class=\"\">Snowflake<\/option>\n<option value=\"tfa_3329\" id=\"tfa_3329\" class=\"\">Somerton<\/option>\n<option value=\"tfa_3330\" id=\"tfa_3330\" class=\"\">South Tucson<\/option>\n<option value=\"tfa_3331\" id=\"tfa_3331\" class=\"\">Sun City<\/option>\n<option value=\"tfa_3332\" id=\"tfa_3332\" class=\"\">Sun City West<\/option>\n<option value=\"tfa_3333\" id=\"tfa_3333\" class=\"\">Sun Lakes<\/option>\n<option value=\"tfa_3334\" id=\"tfa_3334\" class=\"\">Surprise<\/option>\n<option value=\"tfa_3335\" id=\"tfa_3335\" class=\"\">Tanque Verde<\/option>\n<option value=\"tfa_3336\" id=\"tfa_3336\" class=\"\">Tempe<\/option>\n<option value=\"tfa_3337\" id=\"tfa_3337\" class=\"\">Thatcher<\/option>\n<option value=\"tfa_3338\" id=\"tfa_3338\" class=\"\">Tolleson<\/option>\n<option value=\"tfa_3339\" id=\"tfa_3339\" class=\"\">Tuba City<\/option>\n<option value=\"tfa_3340\" id=\"tfa_3340\" class=\"\">Tucson<\/option>\n<option value=\"tfa_3341\" id=\"tfa_3341\" class=\"\">Tucson Estates<\/option>\n<option value=\"tfa_3342\" id=\"tfa_3342\" class=\"\">Vail<\/option>\n<option value=\"tfa_3343\" id=\"tfa_3343\" class=\"\">Valencia West<\/option>\n<option value=\"tfa_3344\" id=\"tfa_3344\" class=\"\">Verde Village<\/option>\n<option value=\"tfa_3345\" id=\"tfa_3345\" class=\"\">Wickenburg<\/option>\n<option value=\"tfa_3346\" id=\"tfa_3346\" class=\"\">Williamson<\/option>\n<option value=\"tfa_3347\" id=\"tfa_3347\" class=\"\">Winslow<\/option>\n<option value=\"tfa_3348\" id=\"tfa_3348\" class=\"\">Youngtown<\/option>\n<option value=\"tfa_3349\" id=\"tfa_3349\" class=\"\">Yuma<\/option>\n<option value=\"tfa_3350\" id=\"tfa_3350\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3180-D\">\n<label id=\"tfa_3180-L\" class=\"label preField \" for=\"tfa_3180\">County<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3180\" name=\"tfa_3180\" title=\"County\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3184\" id=\"tfa_3184\" class=\"\">Maricopa<\/option>\n<option value=\"tfa_3181\" id=\"tfa_3181\" class=\"\">Apache<\/option>\n<option value=\"tfa_3183\" id=\"tfa_3183\" class=\"\">Cochise<\/option>\n<option value=\"tfa_3185\" id=\"tfa_3185\" class=\"\">Coconino<\/option>\n<option value=\"tfa_3186\" id=\"tfa_3186\" class=\"\">Gila<\/option>\n<option value=\"tfa_3187\" id=\"tfa_3187\" class=\"\">Graham<\/option>\n<option value=\"tfa_3188\" id=\"tfa_3188\" class=\"\">Greenlee<\/option>\n<option value=\"tfa_3189\" id=\"tfa_3189\" class=\"\">La Paz<\/option>\n<option value=\"tfa_3190\" id=\"tfa_3190\" class=\"\">Mohave<\/option>\n<option value=\"tfa_3191\" id=\"tfa_3191\" class=\"\">Navajo<\/option>\n<option value=\"tfa_3192\" id=\"tfa_3192\" class=\"\">Pima<\/option>\n<option value=\"tfa_3193\" id=\"tfa_3193\" class=\"\">Pinal<\/option>\n<option value=\"tfa_3194\" id=\"tfa_3194\" class=\"\">Santa Cruz<\/option>\n<option value=\"tfa_3195\" id=\"tfa_3195\" class=\"\">Yavapai<\/option>\n<option value=\"tfa_3196\" id=\"tfa_3196\" class=\"\">Yuma<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3246\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2204-D\">\n<label id=\"tfa_2204-L\" class=\"label preField reqMark\" for=\"tfa_2204\">Child's First Name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2204\" name=\"tfa_2204\" value=\"\" autocomplete=\"off\" title=\"Child's First Name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2206-D\">\n<label id=\"tfa_2206-L\" class=\"label preField reqMark\" for=\"tfa_2206\">Child's Last Name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2206\" name=\"tfa_2206\" value=\"\" autocomplete=\"off\" title=\"Child's Last Name\" class=\"required\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3170\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3449-D\">\n<label id=\"tfa_3449-L\" class=\"label preField \" for=\"tfa_3449\">Date of Birth<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3449\" name=\"tfa_3449\" value=\"\" autocomplete=\"off\" title=\"Date of Birth\" class=\"validate-datecal\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3370-D\">\n<label id=\"tfa_3370-L\" class=\"label preField \" for=\"tfa_3370\">Chosen Pronouns<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3370\" name=\"tfa_3370\" title=\"Chosen Pronouns\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3371\" id=\"tfa_3371\" class=\"\">She\/Her<\/option>\n<option value=\"tfa_3372\" id=\"tfa_3372\" class=\"\">He\/Him<\/option>\n<option value=\"tfa_3373\" id=\"tfa_3373\" class=\"\">They\/Them<\/option>\n<option value=\"tfa_3374\" id=\"tfa_3374\" class=\"\">She\/They<\/option>\n<option value=\"tfa_3375\" id=\"tfa_3375\" class=\"\">He\/They<\/option>\n<option value=\"tfa_3376\" id=\"tfa_3376\" data-conditionals=\"#tfa_3378\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3378-D\">\n<label id=\"tfa_3378-L\" class=\"label preField \" for=\"tfa_3378\">Other Pronouns<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3378\" name=\"tfa_3378\" value=\"\" data-condition=\"`#tfa_3376`\" title=\"Other Pronouns\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3383-D\">\n<label id=\"tfa_3383-L\" class=\"label preField \" for=\"tfa_3383\">Child's Diagnoses:<\/label><br><div class=\"inputWrapper\"><textarea id=\"tfa_3383\" name=\"tfa_3383\" title=\"Child's Diagnoses:\" class=\"\"><\/textarea><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3174-D\">\n<label id=\"tfa_3174-L\" class=\"label preField reqMark\" for=\"tfa_3174\">Needs Information About<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3174\" name=\"tfa_3174\" title=\"Needs Information About\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3216\" id=\"tfa_3216\" class=\"\">General Encircle Families Information<\/option>\n<option value=\"tfa_3217\" id=\"tfa_3217\" class=\"\">Behavior<\/option>\n<option value=\"tfa_3218\" id=\"tfa_3218\" class=\"\">Early Childhood\/Early Intervention<\/option>\n<option value=\"tfa_3219\" id=\"tfa_3219\" class=\"\">Denial of Services<\/option>\n<option value=\"tfa_3220\" id=\"tfa_3220\" class=\"\">Guardianship\/Legal Options at Age 18<\/option>\n<option value=\"tfa_3221\" id=\"tfa_3221\" class=\"\">New Diagnosis<\/option>\n<option value=\"tfa_3237\" id=\"tfa_3237\" class=\"\">NICU<\/option>\n<option value=\"tfa_3222\" id=\"tfa_3222\" class=\"\">Special Education - Evaluation\/Eligibility<\/option>\n<option value=\"tfa_3223\" id=\"tfa_3223\" class=\"\">Special Education - IEP<\/option>\n<option value=\"tfa_3224\" id=\"tfa_3224\" class=\"\">Special Education - Placement<\/option>\n<option value=\"tfa_3225\" id=\"tfa_3225\" class=\"\">Special Education - Dispute Resolution<\/option>\n<option value=\"tfa_3226\" id=\"tfa_3226\" class=\"\">Transition to Adulthood<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3384-D\">\n<label id=\"tfa_3384-L\" class=\"label preField \" for=\"tfa_3384\">Additional Information<\/label><br><div class=\"inputWrapper\"><textarea id=\"tfa_3384\" name=\"tfa_3384\" title=\"Additional Information\" class=\"\"><\/textarea><\/div>\n<\/div>\n<div class=\"htmlSection\" id=\"tfa_3452\"><div class=\"htmlContent\" id=\"tfa_3452-HTML\"><i>By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. You will receive no more than two attempts to reach you via SMS text message. Message &amp; data rates may apply. You can reply STOP at any time to opt-out of further messaging. For help, please call 602-242-4366.<\/i><\/div><\/div>\n<\/fieldset>\n<fieldset id=\"tfa_3389\" class=\"section\" data-condition=\"`#tfa_3236`\">\n<legend id=\"tfa_3389-L\">Optional Information<\/legend>\n<div class=\"htmlSection\" id=\"tfa_3450\"><div class=\"htmlContent\" id=\"tfa_3450-HTML\">This information helps us ensure that we are serving our entire community. This section is optional and has no impact on the availability of services from Encircle Families. Our services are always available at no cost to all Arizona families.<\/div><\/div>\n<div id=\"tfa_3398\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3390-D\">\n<label id=\"tfa_3390-L\" class=\"label preField \" for=\"tfa_3390\">Race<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3390\" name=\"tfa_3390\" title=\"Race\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3393\" id=\"tfa_3393\" class=\"\">Asian<\/option>\n<option value=\"tfa_3391\" id=\"tfa_3391\" class=\"\">Black or African American<\/option>\n<option value=\"tfa_3392\" id=\"tfa_3392\" class=\"\">Native American\/American Indian or Alaskan Native<\/option>\n<option value=\"tfa_3446\" id=\"tfa_3446\" class=\"\">Native Hawaiian or Pacific Islander<\/option>\n<option value=\"tfa_3447\" id=\"tfa_3447\" class=\"\">White<\/option>\n<option value=\"tfa_3448\" id=\"tfa_3448\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3394-D\">\n<label id=\"tfa_3394-L\" class=\"label preField \" for=\"tfa_3394\">Ethnicity<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3394\" name=\"tfa_3394\" title=\"Ethnicity\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3395\" id=\"tfa_3395\" class=\"\">Non-Hispanic or Non-Latino<\/option>\n<option value=\"tfa_3396\" id=\"tfa_3396\" class=\"\">Hispanic or Latino<\/option>\n<option value=\"tfa_3397\" id=\"tfa_3397\" class=\"\">Unknown<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3399-D\">\n<label id=\"tfa_3399-L\" class=\"label preField \" for=\"tfa_3399\">Do You Receive Public Assistance&nbsp;<\/label><br><div class=\"inputWrapper\">\n<select id=\"tfa_3399\" name=\"tfa_3399\" title=\"Do You Receive Public Assistance \" aria-describedby=\"tfa_3399-HH\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3400\" id=\"tfa_3400\" data-conditionals=\"#tfa_3402,#tfa_3410\" class=\"\">Yes<\/option>\n<option value=\"tfa_3401\" id=\"tfa_3401\" class=\"\">No<\/option><\/select><span class=\"field-hint-inactive\" id=\"tfa_3399-H\"><span id=\"tfa_3399-HH\" class=\"hint\">Examples include free school lunches, Income-based AHCCCS, SNAP.<\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3402-D\">\n<label id=\"tfa_3402-L\" class=\"label preField \" for=\"tfa_3402\"># of Household Members<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3402\" name=\"tfa_3402\" data-filter-dependent=\"#tfa_3410\" data-condition=\"`#tfa_3400`\" title=\"# of Household Members\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3403\" id=\"tfa_3403\" class=\"\">2<\/option>\n<option value=\"tfa_3404\" id=\"tfa_3404\" class=\"\">3<\/option>\n<option value=\"tfa_3405\" id=\"tfa_3405\" class=\"\">4<\/option>\n<option value=\"tfa_3406\" id=\"tfa_3406\" class=\"\">5<\/option>\n<option value=\"tfa_3407\" id=\"tfa_3407\" class=\"\">6<\/option>\n<option value=\"tfa_3408\" id=\"tfa_3408\" class=\"\">7<\/option>\n<option value=\"tfa_3409\" id=\"tfa_3409\" class=\"\">8+<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3410-D\">\n<label id=\"tfa_3410-L\" class=\"label preField \" for=\"tfa_3410\">Household Income<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_3410\" name=\"tfa_3410\" data-filter-control=\"#tfa_3402\" data-condition=\"`#tfa_3400`\" title=\"Household Income\" class=\"\"><option value=\"\">Please select...<\/option>\n<optgroup id=\"tfa_3414\" label=\"2\" class=\"choiceGroup\">\n<option value=\"tfa_3411\" id=\"tfa_3411\" class=\"\">$22,600 or less<\/option>\n<option value=\"tfa_3412\" id=\"tfa_3412\" class=\"\">$22,601 - $37,700<\/option>\n<option value=\"tfa_3413\" id=\"tfa_3413\" class=\"\">$37,701 - $60,300<\/option>\n<option value=\"tfa_3421\" id=\"tfa_3421\" class=\"\">$60,301+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3415\" label=\"3\" class=\"choiceGroup\">\n<option value=\"tfa_3422\" id=\"tfa_3422\" class=\"\">$25,450 or less<\/option>\n<option value=\"tfa_3423\" id=\"tfa_3423\" class=\"\">$25,451 - $42,400<\/option>\n<option value=\"tfa_3424\" id=\"tfa_3424\" class=\"\">$42,401 - $67,850<\/option>\n<option value=\"tfa_3425\" id=\"tfa_3425\" class=\"\">$67,851+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3416\" label=\"4\" class=\"choiceGroup\">\n<option value=\"tfa_3426\" id=\"tfa_3426\" class=\"\">$28,250 or less<\/option>\n<option value=\"tfa_3427\" id=\"tfa_3427\" class=\"\">$28,251 - $47,100<\/option>\n<option value=\"tfa_3428\" id=\"tfa_3428\" class=\"\">$47,101 - $75,350<\/option>\n<option value=\"tfa_3429\" id=\"tfa_3429\" class=\"\">$75,351+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3417\" label=\"5\" class=\"choiceGroup\">\n<option value=\"tfa_3430\" id=\"tfa_3430\" class=\"\">$30,550 or less<\/option>\n<option value=\"tfa_3431\" id=\"tfa_3431\" class=\"\">$30,551 - $50,900<\/option>\n<option value=\"tfa_3432\" id=\"tfa_3432\" class=\"\">$50,901 - $81,400<\/option>\n<option value=\"tfa_3433\" id=\"tfa_3433\" class=\"\">$81,401+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3418\" label=\"6\" class=\"choiceGroup\">\n<option value=\"tfa_3434\" id=\"tfa_3434\" class=\"\">$32,800 or less<\/option>\n<option value=\"tfa_3435\" id=\"tfa_3435\" class=\"\">$32,801 - $54,650<\/option>\n<option value=\"tfa_3436\" id=\"tfa_3436\" class=\"\">$54,651 - $87,450<\/option>\n<option value=\"tfa_3437\" id=\"tfa_3437\" class=\"\">$87,451+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3419\" label=\"7\" class=\"choiceGroup\">\n<option value=\"tfa_3438\" id=\"tfa_3438\" class=\"\">$35,050 or less<\/option>\n<option value=\"tfa_3439\" id=\"tfa_3439\" class=\"\">$35,051 - $58,450<\/option>\n<option value=\"tfa_3440\" id=\"tfa_3440\" class=\"\">$58,451 - $93,450<\/option>\n<option value=\"tfa_3441\" id=\"tfa_3441\" class=\"\">$93,451+<\/option>\n<\/optgroup>\n<optgroup id=\"tfa_3420\" label=\"8+\" class=\"choiceGroup\">\n<option value=\"tfa_3442\" id=\"tfa_3442\" class=\"\">$37,300 or less<\/option>\n<option value=\"tfa_3443\" id=\"tfa_3443\" class=\"\">$37,301 - $62,200<\/option>\n<option value=\"tfa_3444\" id=\"tfa_3444\" class=\"\">$62,201 - $99,500<\/option>\n<option value=\"tfa_3445\" id=\"tfa_3445\" class=\"\">$99,501+<\/option>\n<\/optgroup><\/select><\/div>\n<\/div>\n<\/fieldset>\n<input type=\"hidden\" id=\"tfa_3379\" name=\"tfa_3379\" value=\"\" class=\"\"><div class=\"actions\" id=\"5157846-A\" data-contentid=\"submit_button\">\n<div id=\"google-captcha\" style=\"display: none\">\n<br><div class=\"captcha\">\n<div class=\"oneField\">\n<div class=\"g-recaptcha\" id=\"g-recaptcha-render-div\"><\/div>\n<div class=\"g-captcha-error\"><\/div>\n<br>\n<\/div>\n<div class=\"captchaHelp\">reCAPTCHA helps prevent automated form spam.<br>\n<\/div>\n<div id=\"disabled-explanation\" class=\"captchaHelp\" style=\"display: none\">The submit button will be disabled until you complete the CAPTCHA.<\/div>\n<\/div>\n<\/div>\n<input type=\"submit\" data-label=\"Submit\" class=\"primaryAction\" id=\"submit_button\" value=\"Submit\" data-condition=\"`#tfa_3458` OR `#tfa_3236`\" data-conditional-mode=\"hidden\">\n<\/div>\n<div style=\"clear:both\"><\/div>\n<input type=\"hidden\" value=\"591-f9b9a667744110a4ed0315e4f0a60ffa\" name=\"tfa_dbCounters\" id=\"tfa_dbCounters\" autocomplete=\"off\"><input type=\"hidden\" value=\"5157846\" name=\"tfa_dbFormId\" id=\"tfa_dbFormId\"><input type=\"hidden\" value=\"\" name=\"tfa_dbResponseId\" id=\"tfa_dbResponseId\"><input type=\"hidden\" value=\"afb8ba5f546877a2c8349d194a0df6b7\" name=\"tfa_dbControl\" id=\"tfa_dbControl\"><input type=\"hidden\" value=\"\" name=\"tfa_dbWorkflowSessionUuid\" id=\"tfa_dbWorkflowSessionUuid\"><input type=\"hidden\" value=\"1776639569\" name=\"tfa_dbTimeStarted\" id=\"tfa_dbTimeStarted\" autocomplete=\"off\"><input type=\"hidden\" value=\"31\" name=\"tfa_dbVersionId\" id=\"tfa_dbVersionId\"><input type=\"hidden\" value=\"\" name=\"tfa_switchedoff\" id=\"tfa_switchedoff\">\n<\/form>\n<\/div><\/div><div class=\"wFormFooter\"><p class=\"supportInfo\"><a target=\"new\" class=\"contactInfoLink\" href=\"https:\/\/www.tfaforms.com\/forms\/help\/5157846\" data-testid=\"contact-info-link\">Contact Information<\/a><br><\/p><\/div>\n  <p class=\"supportInfo\" >\n      <\/p>\n <\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":2885,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"default","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"default","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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