{"id":220,"date":"2022-03-08T16:39:18","date_gmt":"2022-03-08T21:39:18","guid":{"rendered":"https:\/\/fireflyin.org\/?page_id=220"},"modified":"2026-02-27T13:24:11","modified_gmt":"2026-02-27T18:24:11","slug":"community-partners-for-child-safety","status":"publish","type":"page","link":"https:\/\/fireflyin.org\/zh\/programs-services\/child-abuse-prevention\/community-partners-for-child-safety\/","title":{"rendered":"\u513f\u7ae5\u5b89\u5168\u793e\u533a\u5408\u4f5c\u4f19\u4f34 (CPCS)"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(42,62,80,0.4)&#8221; background_image=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2023\/02\/iStock-1389444842.jpg&#8221; background_blend=&#8221;overlay&#8221; custom_padding=&#8221;200px||200px||true|false&#8221; custom_padding_tablet=&#8221;100px||100px||true|false&#8221; custom_padding_phone=&#8221;70px||70px||true|false&#8221; bottom_divider_style=&#8221;curve&#8221; bottom_divider_color=&#8221;#EEEDEB&#8221; bottom_divider_height=&#8221;60px&#8221; bottom_divider_height_tablet=&#8221;30px&#8221; bottom_divider_height_phone=&#8221;30px&#8221; bottom_divider_height_last_edited=&#8221;on|tablet&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.17.0&#8243; _module_preset=&#8221;default&#8221; header_font=&#8221;|800||on|||||&#8221; header_font_size=&#8221;65px&#8221; text_orientation=&#8221;center&#8221; background_layout=&#8221;dark&#8221; custom_margin=&#8221;||0px||false|false&#8221; header_font_size_tablet=&#8221;40px&#8221; header_font_size_phone=&#8221;35px&#8221; header_font_size_last_edited=&#8221;on|desktop&#8221; header_text_shadow_style=&#8221;preset3&#8243; header_text_shadow_color=&#8221;rgba(0,0,0,0.7)&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>COMMUNITY PARTNERS FOR CHILD SAFETY<\/h1>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.0&#8243; _module_preset=&#8221;default&#8221; header_2_font_size=&#8221;19px&#8221; text_orientation=&#8221;center&#8221; background_layout=&#8221;dark&#8221; header_2_font_size_tablet=&#8221;19px&#8221; header_2_font_size_phone=&#8221;17px&#8221; header_2_font_size_last_edited=&#8221;on|desktop&#8221; header_2_text_shadow_style=&#8221;preset3&#8243; header_2_text_shadow_color=&#8221;rgba(0,0,0,0.9)&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Investing in the next generation through child abuse prevention and awareness<\/h2>\n<p>[\/et_pb_text][et_pb_button button_url=&#8221;#contactcpcsteam&#8221; button_text=&#8221;Refer a Family or Your Own&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_button][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#EEEDEB&#8221; custom_padding=&#8221;90px||90px||true|false&#8221; custom_padding_tablet=&#8221;70px||70px||true|false&#8221; custom_padding_phone=&#8221;50px||50px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row make_equal=&#8221;on&#8221; module_class=&#8221;vert_alg&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2022\/03\/dots.png&#8221; title_text=&#8221;dots&#8221; align=&#8221;center&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; header_2_font=&#8221;|800||on|||||&#8221; header_2_font_size=&#8221;40px&#8221; header_2_letter_spacing=&#8221;1px&#8221; text_orientation=&#8221;center&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_2_font_size_tablet=&#8221;35px&#8221; header_2_font_size_phone=&#8221;30px&#8221; header_2_font_size_last_edited=&#8221;on|desktop&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Working together to prevent child abuse and neglect<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; text_orientation=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]Firefly Children and Family Alliance is the largest child abuse prevention provider in central Indiana. The agency assumed this responsibility in 1999 when a federally funded grant supported the pilot of the Neighborhood Alliance for Child Safety Program (NACS) in Marion County. The impact of the NACS program on child abuse prevention was so successful that it expanded throughout central Indiana and was renamed Community Partners for Child Safety. The program is voluntary and designed to ensure safe, stable homes for children. CPCS provides community support to vulnerable families located in central Indiana that self-identify or are referred by community agencies, schools, churches, relatives and other community systems.[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; z_index=&#8221;99&#8243; custom_padding=&#8221;90px||90px||true|false&#8221; custom_padding_tablet=&#8221;70px||70px||true|false&#8221; custom_padding_phone=&#8221;50px||50px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;2_5,3_5&#8243; make_equal=&#8221;on&#8221; module_class=&#8221;vert_alg&#8221; _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||60px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2023\/02\/iStock-1319065654.jpg&#8221; title_text=&#8221;Mother breastfeeding baby.&#8221; show_bottom_space=&#8221;off&#8221; force_fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||0px||false|false&#8221; border_width_right=&#8221;10px&#8221; border_color_right=&#8221;#8CBA45&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; header_3_font=&#8221;|800|||||||&#8221; header_3_font_size=&#8221;30px&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;35px&#8221; header_3_font_size_phone=&#8221;30px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>What\u2019s offered through Community Partners for Child Safety?<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]Providing services in the home is the first step in identifying underlying issues that can lead to instability and unsafe environments for children. Trained case managers help families understand the importance of defining and working toward family-specific goals. Goals often include securing safe, affordable housing; seeking employment or advancing job skills; learning and using constructive communication and parenting skills and connecting families to resources to address addictions and mental health concerns. The case manager is key in identifying necessary community resources, initiating referrals and ultimately supporting families.[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=&#8221;3_5,2_5&#8243; make_equal=&#8221;on&#8221; module_class=&#8221;vert_alg custom_row&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||60px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;3_5&#8243; module_class=&#8221;second-on-mobile&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; header_3_font=&#8221;|800|||||||&#8221; header_3_font_size=&#8221;30px&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;35px&#8221; header_3_font_size_phone=&#8221;30px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>Who\u2019s eligible for Community Partners for Child Safety?<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<ul>\n<li>Families with children under age 18 who reside in one of the service areas<\/li>\n<li>Families who are not actively involved with the Indiana Department of Child Services or Healthy Families<\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;2_5&#8243; module_class=&#8221;first-on-mobile&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2023\/02\/iStock-1366689803.jpg&#8221; alt=&#8221;Who&#8217;s Eligible&#8221; title_text=&#8221;A competitive mortgage rate could be closer than you know.&#8221; force_fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; border_width_left=&#8221;10px&#8221; border_color_left=&#8221;#8CBA45&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=&#8221;1_2,1_2&#8243; make_equal=&#8221;on&#8221; module_class=&#8221;vert_alg&#8221; _builder_version=&#8221;4.16.0&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||60px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2025\/09\/cpcs-region-map-9.4.25.jpg&#8221; title_text=&#8221;CPCS Region Map 2025&#8243; show_bottom_space=&#8221;off&#8221; force_fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; header_3_font=&#8221;|800|||||||&#8221; header_3_font_size=&#8221;30px&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;35px&#8221; header_3_font_size_phone=&#8221;30px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>Where is Community Partners for Child Safety offered?<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]The program is offered in 33 Indiana counties and through the following Firefly office locations: Muncie, Anderson, Terre Haute, Plainfield, Indianapolis, Noblesville, Greenfield, Connersville, New Whiteland, Columbus, and Wabash.<br \/>\n[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; header_3_font=&#8221;|800|||||||&#8221; header_3_font_size=&#8221;30px&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;35px&#8221; header_3_font_size_phone=&#8221;30px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>2026 Bidders Conferences<\/h3>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Click below regarding more information for your region.<br \/><a href=\"https:\/\/fireflyin.org\/wp-content\/uploads\/2026\/02\/2026-Region-10-bidders-conference-announcement.docx\" rel=\"attachment wp-att-87193\">2026 Region 10 Bidders Conference<\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; header_3_font=&#8221;|800|||||||&#8221; header_3_font_size=&#8221;30px&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;35px&#8221; header_3_font_size_phone=&#8221;30px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>Contact Us<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]Do you need to refer someone to the Community Partners for Child Safety program? Use the form below to get in touch with us.<br \/>\n[\/et_pb_text][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2024\/03\/CPCS_Green_Horizontal_Full-2-300&#215;81.png&#8221; title_text=&#8221;CPCS_Green_Horizontal_Full (2)&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][et_pb_accordion disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_accordion_item title=&#8221;Your Title Goes Here&#8221; open=&#8221;on&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.<br \/>\n[\/et_pb_accordion_item][et_pb_accordion_item title=&#8221;Your Title Goes Here&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221; open=&#8221;off&#8221;]Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.<br \/>\n[\/et_pb_accordion_item][\/et_pb_accordion][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_id=&#8221;contactcpcsteam&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#eeedeb&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;1_2,1_2&#8243; make_equal=&#8221;on&#8221; module_class=&#8221;vert_alg&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||60px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_image src=&#8221;https:\/\/fireflyin.org\/wp-content\/uploads\/2022\/03\/dots.png&#8221; title_text=&#8221;dots&#8221; _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][et_pb_text _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; header_2_font=&#8221;|800||on|||||&#8221; header_2_text_align=&#8221;left&#8221; header_2_font_size=&#8221;40px&#8221; header_2_letter_spacing=&#8221;1px&#8221; header_2_font_size_tablet=&#8221;40px&#8221; header_2_font_size_phone=&#8221;40px&#8221; header_2_font_size_last_edited=&#8221;on|desktop&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Contact Us<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.1&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]Interested in learning more about Firefly Children and Family Alliance? Reach out today for more information.[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3 style=\"text-align: center;\"><strong>Providers and DCS Employees: <span style=\"text-decoration: underline;\">Our web form is currently experiencing an outage<\/span>. We are working on a fix ASAP.<\/strong><\/h3>\n<h3 style=\"text-align: center;\"><span style=\"text-decoration: underline;\"><strong>Please email referrals directly to your regional email or <a href=\"CPCSinquiries@fireflyIN.org\">CPCSinquiries@fireflyIN.org<\/a>.<\/strong><\/span><\/h3>\n<p>[\/et_pb_text][et_pb_code disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.19.2&#8243; _module_preset=&#8221;default&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f11469-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"11469\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/zh\/wp-json\/wp\/v2\/pages\/220#wpcf7-f11469-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"11469\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f11469-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-referral\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"your-referral\"><option value=\"\">I am referring*...<\/option><option value=\"A Family\">A Family<\/option><option value=\"A Person In Need\">A Person In Need<\/option><\/select><\/span><\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-region\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"your-region\"><option value=\"\">Select a region* (see map)<\/option><option value=\"Region 7\">Region 7<\/option><option value=\"Region 8\">Region 8<\/option><option value=\"Region 9\">Region 9<\/option><option value=\"Region 10\">Region 10<\/option><option value=\"Region 11\">Region 11<\/option><option value=\"Region 12\">Region 12<\/option><option value=\"Region 14\">Region 14<\/option><\/select><\/span><\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Family Name*\" value=\"\" type=\"text\" name=\"family-name\" \/><\/span><\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"family-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Family&#039;s Phone Number*\" value=\"\" type=\"text\" name=\"family-address\" \/><\/span><\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"referral-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referral Name*\" value=\"\" type=\"text\" name=\"referral-name\" \/><\/span><\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"referral-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referral Email*\" value=\"\" type=\"email\" name=\"referral-email\" \/><\/span> <\/label>\n<\/p>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"How can we help?*\" name=\"your-message\"><\/textarea><\/span><\/label><br \/>\n<label>\n\t<\/label><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><input type=\"hidden\" id=\"ct_checkjs_cf7_ab233b682ec355648e7891e66c54191b\" name=\"ct_checkjs_cf7\" value=\"0\" \/><script >setTimeout(function(){var ct_input_name = \"ct_checkjs_cf7_ab233b682ec355648e7891e66c54191b\";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, '59570bddfaf7c20ac66bde5bb4fd2e5119d2fd7db1a3a83f995a8e34099e15b2');}}, 1000);<\/script><input\n                    class=\"apbct_special_field apbct_email_id__wp_contact_form_7\"\n                    name=\"apbct__email_id__wp_contact_form_7\"\n                    aria-label=\"apbct__label_id__wp_contact_form_7\"\n                    type=\"text\" size=\"30\" maxlength=\"200\" autocomplete=\"off\"\n                    value=\"\"\n                \/><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"109\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/et_pb_code][et_pb_code disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<div class='fluentform ff-default fluentform_wrapper_7 ffs_default_wrap'><form data-form_id=\"7\" id=\"fluentform_7\" class=\"frm-fluent-form fluent_form_7 ff-el-form-top ff_form_instance_7_1 ff-form-loading ff_has_v3_recptcha ffs_default\" data-form_instance=\"ff_form_instance_7_1\" method=\"POST\" data-recptcha_key=\"6LcNmFogAAAAANf9lmg1yN8XceAk5OO0Yo2DQ5gV\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">CPCS Referral Form (Fluent Forms)<\/legend><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"ak_js\" value=\"34\"\/><script>document.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='220' \/><input type=\"hidden\" id=\"_fluentform_7_fluentformnonce\" name=\"_fluentform_7_fluentformnonce\" value=\"c8fbd153f8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/zh\/wp-json\/wp\/v2\/pages\/220\" \/><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown_4' id='label_ff_7_dropdown_4' aria-label=\"Select a region\">Select a region<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_7_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown_4\"><option value=\"\">- Select -<\/option><option value=\"region6@fireflyIN.org\"  >Region 6 (Cass, Fulton, Howard, Huntington, Miami, Wabash)<\/option><option value=\"Region7@FireflyIN.org\"  >Region 7 (Adams, Blackford, Delaware, Grant, Jay, Randolph, Wells)<\/option><option value=\"Region8@fireflyIN.org\"  >Region 8 (Clay, Parke, Sullivan, Vermillion, Vigo)<\/option><option value=\"region9@FireflyIN.org\"  >Region 9 (Boone, Hendricks, Montgomery, Morgan, Putnam)<\/option><option value=\"CPCSinquiries@fireflyIN.org\"  >Region 10 (Marion)<\/option><option value=\"region11@FireflyIN.org\"  >Region 11 (Hamilton, Hancock, Madison, Tipton)<\/option><option value=\"region12@FireflyIN.org\"  >Region 12 (Fayette, Franklin, Henry, Rush, Union, Wayne)<\/option><option value=\"region14@FireflyIN.org\"  >Region 14 (Bartholomew, Jackson, Jennings, Johnson, Shelby)<\/option><\/select><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_4' id='label_ff_7_input_text_4' aria-label=\"Referral Source First Name\">Referral Source First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" placeholder=\"First Name\" data-name=\"input_text_4\" id=\"ff_7_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_5' id='label_ff_7_input_text_5' aria-label=\"Referral Source Last Name\">Referral Source Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" placeholder=\"Last Name\" data-name=\"input_text_5\" id=\"ff_7_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_7' id='label_ff_7_input_text_7' aria-label=\"Primary Language Spoken at Home\">Primary Language Spoken at Home<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_7_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_1' id='label_ff_7_input_text_1' aria-label=\"Family\/Parent(s) Names\">Family\/Parent(s) Names<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"Family\/Parent(s) Names\" data-name=\"input_text_1\" id=\"ff_7_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_numeric-field_1' id='label_ff_7_numeric-field_1' aria-label=\"Number of Children in Home\">Number of Children in Home<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_1\" id=\"ff_7_numeric-field_1\" class=\"ff-el-form-control\" placeholder=\"Number of Children in Home\" data-name=\"numeric-field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_multi_select' id='label_ff_7_multi_select' aria-label=\"Who are you filling this form out for?\">Who are you filling this form out for?<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select[]\" id=\"ff_7_multi_select\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_multi_select\"><option value=\"Myself\"  >Myself<\/option><option value=\"Someone else\"  >Someone else<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_input_text_8' id='label_ff_7_input_text_8' aria-label=\"If you selected &quot;someone else,&quot; please list their name(s) and contact information:\">If you selected \"someone else,\" please list their name(s) and contact information:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_7_input_text_8\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_input_text_2' id='label_ff_7_input_text_2' aria-label=\"Children&#039;s Names\/Ages\">Children's Names\/Ages<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_7_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_6' id='label_ff_7_input_text_6' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" placeholder=\"Phone Number\" data-name=\"input_text_6\" id=\"ff_7_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_email' id='label_ff_7_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_7_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_address_1_address_line_1_' id='label_ff_7_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_7_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_address_1_address_line_2_' id='label_ff_7_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_7_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_address_1_city_' id='label_ff_7_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_7_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_address_1_state_' id='label_ff_7_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_7_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_address_1_zip_' id='label_ff_7_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_7_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown' id='label_ff_7_dropdown' aria-label=\"Are you currently working with Healthy Families?\">Are you currently working with Healthy Families?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_7_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown_1' id='label_ff_7_dropdown_1' aria-label=\"Are you currently working with Child Protective Services?\">Are you currently working with Child Protective Services?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_7_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown_1\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown_2' id='label_ff_7_dropdown_2' aria-label=\"Are you currently working with the juvenile probation system?\">Are you currently working with the juvenile probation system?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_7_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown_2\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown_3' id='label_ff_7_dropdown_3' aria-label=\"Any bed bug issues?\">Any bed bug issues?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_7_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown_3\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Please check the areas in which you would like to receive more information or need assistance:\">Please check the areas in which you would like to receive more information or need assistance:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8916bc53e50d04d5d1d8e494b1e09bef'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Family planning\"  id='checkbox_8916bc53e50d04d5d1d8e494b1e09bef' aria-label='Family planning' aria-invalid='false' aria-required=true> <span>Family planning<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_41ccdcfcde6538c2d5e03cbfb1922224'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pregnancy\/Birth\"  id='checkbox_41ccdcfcde6538c2d5e03cbfb1922224' aria-label='Pregnancy\/Birth' aria-invalid='false' aria-required=true> <span>Pregnancy\/Birth<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_47f041b34ef33661d25d4336c354f53e'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Newborn\"  id='checkbox_47f041b34ef33661d25d4336c354f53e' aria-label='Newborn' aria-invalid='false' aria-required=true> <span>Newborn<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_35392fb1387d6d70476626bf8c4cd011'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Child Care\"  id='checkbox_35392fb1387d6d70476626bf8c4cd011' aria-label='Child Care' aria-invalid='false' aria-required=true> <span>Child Care<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_870efd318807a6d2fc98dbc256ce26ed'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"School\/Education\"  id='checkbox_870efd318807a6d2fc98dbc256ce26ed' aria-label='School\/Education' aria-invalid='false' aria-required=true> <span>School\/Education<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_a35df56cb1630fe404c6170c6b5713a6'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"After-school activities\"  id='checkbox_a35df56cb1630fe404c6170c6b5713a6' aria-label='After-school activities' aria-invalid='false' aria-required=true> <span>After-school activities<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_fa4f7d99911b0cdb0a8eab63f338c15c'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Social\/recreational supports\"  id='checkbox_fa4f7d99911b0cdb0a8eab63f338c15c' aria-label='Social\/recreational supports' aria-invalid='false' aria-required=true> <span>Social\/recreational supports<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_c44063c809fc585ca177140692f8edfb'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Food\"  id='checkbox_c44063c809fc585ca177140692f8edfb' aria-label='Food' aria-invalid='false' aria-required=true> <span>Food<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_dfa410ace4a25eaad1ba090972945f68'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Clothing\"  id='checkbox_dfa410ace4a25eaad1ba090972945f68' aria-label='Clothing' aria-invalid='false' aria-required=true> <span>Clothing<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_dbc2a3687922a02421e015f6ce52c564'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Housing\"  id='checkbox_dbc2a3687922a02421e015f6ce52c564' aria-label='Housing' aria-invalid='false' aria-required=true> <span>Housing<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3cf74ebfd84bee4fea79aec593554d37'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Utilities\"  id='checkbox_3cf74ebfd84bee4fea79aec593554d37' aria-label='Utilities' aria-invalid='false' aria-required=true> <span>Utilities<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_c4a679f8a6908cabaca8bb1ae0b693a1'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Transportation\"  id='checkbox_c4a679f8a6908cabaca8bb1ae0b693a1' aria-label='Transportation' aria-invalid='false' aria-required=true> <span>Transportation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3ab27a33bef998b2ea9bbc7f3498d22a'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Employment\"  id='checkbox_3ab27a33bef998b2ea9bbc7f3498d22a' aria-label='Employment' aria-invalid='false' aria-required=true> <span>Employment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_ab6bd4291d0a8fc8c411361c9a76ef36'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Money management\"  id='checkbox_ab6bd4291d0a8fc8c411361c9a76ef36' aria-label='Money management' aria-invalid='false' aria-required=true> <span>Money management<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_750ae9748fd7626e5a1fb9812c12f644'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Parenting Information\"  id='checkbox_750ae9748fd7626e5a1fb9812c12f644' aria-label='Parenting Information' aria-invalid='false' aria-required=true> <span>Parenting Information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_04b9210984c87ec254ac4a8ce87a758f'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Substance abuse information\"  id='checkbox_04b9210984c87ec254ac4a8ce87a758f' aria-label='Substance abuse information' aria-invalid='false' aria-required=true> <span>Substance abuse information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_891c2ae40c44f9dfa4e871d8ca528ad0'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mental health information\"  id='checkbox_891c2ae40c44f9dfa4e871d8ca528ad0' aria-label='Mental health information' aria-invalid='false' aria-required=true> <span>Mental health information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_fdd537d2594048af6a6cca95bfa7e1b5'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Medical\/dental information\"  id='checkbox_fdd537d2594048af6a6cca95bfa7e1b5' aria-label='Medical\/dental information' aria-invalid='false' aria-required=true> <span>Medical\/dental information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_290e2bf806cbf2d0f0ef5b04d8694f55'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Legal information\"  id='checkbox_290e2bf806cbf2d0f0ef5b04d8694f55' aria-label='Legal information' aria-invalid='false' aria-required=true> <span>Legal information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4fd8176b7ad5124ce050a2faae135bae'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Spiritual information\"  id='checkbox_4fd8176b7ad5124ce050a2faae135bae' aria-label='Spiritual information' aria-invalid='false' aria-required=true> <span>Spiritual information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_a53df1d03a857d285f90467c69107298'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Health\/hygiene information\"  id='checkbox_a53df1d03a857d285f90467c69107298' aria-label='Health\/hygiene information' aria-invalid='false' aria-required=true> <span>Health\/hygiene information<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_description' id='label_ff_7_description' aria-label=\"Other Needs\/Comments\">Other Needs\/Comments<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_7_description\" name=\"description\" id=\"ff_7_description\" class=\"ff-el-form-control\" placeholder=\"Other Needs\/Comments\" rows=\"1\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_input_text' id='label_ff_7_input_text' aria-label=\"How did you learn about us?\">How did you learn about us?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"How did you learn about us?\" data-name=\"input_text\" id=\"ff_7_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_input_text_3' 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' ><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/zh\/wp-json\/wp\/v2\/pages\/220#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_3\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Select a region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_2_3' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='region6@fireflyIN.org' >Region F (Cass, Fulton, Howard, Huntington, Miami, Wabash)<\/option><option value='Region7@FireflyIN.org' >Region G (Adams, Blackford, Delaware, Grant, Jay, Randolph, Wells)<\/option><option value='Region8@fireflyIN.org' >Region H (Clay, Parke, Sullivan, Vermillion, Vigo)<\/option><option value='region9@FireflyIN.org' >Region I (Boone, Hendricks, Montgomery, Morgan, Putnam)<\/option><option value='CPCSinquiries@fireflyIN.org' >Region J (Marion)<\/option><option value='region11@FireflyIN.org' >Region K (Hamilton, Hancock, Madison, Tipton)<\/option><option value='region12@FireflyIN.org' >Region L (Fayette, Franklin, Henry, Rush, Union, Wayne)<\/option><option value='region14@FireflyIN.org' >Region N (Bartholomew, Jackson, Jennings, Johnson, Shelby)<\/option><\/select><\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_5'>\n                            \n                            <span id='input_2_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_5_3' class='gform-field-label gform-field-label--type-sub '>Referral Source First Name<span>*<\/span><\/label>\n                                                    <input type='text' name='input_5.3' id='input_2_5_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_2_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_5_6' class='gform-field-label gform-field-label--type-sub '>Referral Source Last Name<span>*<\/span><\/label>\n                                                            <input type='text' name='input_5.6' id='input_2_5_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Primary Language Spoken at Home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Family\/Parent(s) Names<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='large'    placeholder='Family\/Parent(s) Names' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Number of Children in Home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large'    placeholder='Number of Children in Home' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Who are you filling this form out for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_2_28' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='Myself' >Myself<\/option><option value='Someone else' >Someone else<\/option><\/select><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>If you selected &quot;someone else,&quot; please list their name(s) and contact information:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Children&#039;s Names\/Ages<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_2_14' type='tel' value='' class='large'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_2_15' type='email' value='' class='large'   placeholder='Email Address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_2_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_16_1_container' >\n                                        <label for='input_2_16_1' id='input_2_16_1_label' class='gform-field-label gform-field-label--type-sub '>Address Line 1<span>*<\/span><\/label>\n                                        <input type='text' name='input_16.1' id='input_2_16_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_16_2_container' >\n                                        <label for='input_2_16_2' id='input_2_16_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_16.2' id='input_2_16_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_16_3_container' >\n                                    <label for='input_2_16_3' id='input_2_16_3_label' class='gform-field-label gform-field-label--type-sub '>City<span>*<\/span><\/label>\n                                    <input type='text' name='input_16.3' id='input_2_16_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_16_4_container' >\n                                        <label for='input_2_16_4' id='input_2_16_4_label' class='gform-field-label gform-field-label--type-sub '>State<span>*<\/span><\/label>\n                                        <input type='text' name='input_16.4' id='input_2_16_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_16_5_container' >\n                                    <label for='input_2_16_5' id='input_2_16_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<span>*<\/span><\/label>\n                                    <input type='text' name='input_16.5' id='input_2_16_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_16.6' id='input_2_16_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_18\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Are you currently working with Healthy Families?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_2_18' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Are you currently working with Child Protective Services?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_2_19' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Are you currently working with the juvenile probation system?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_2_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Any bed bug issues?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_2_21' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Select -<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please check the areas in which you would like to receive more information or need assistance:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Family planning'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Family planning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Pregnancy\/Birth'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Pregnancy\/Birth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Newborn'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Newborn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Child Care'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Child Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='School\/Education'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>School\/Education<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='After-school activities'  id='choice_2_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_6' id='label_2_22_6' class='gform-field-label gform-field-label--type-inline'>After-school activities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.7' type='checkbox'  value='Social\/recreational supports'  id='choice_2_22_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_7' id='label_2_22_7' class='gform-field-label gform-field-label--type-inline'>Social\/recreational supports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.8' type='checkbox'  value='Food'  id='choice_2_22_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_8' id='label_2_22_8' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.9' type='checkbox'  value='Clothing'  id='choice_2_22_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_9' id='label_2_22_9' class='gform-field-label gform-field-label--type-inline'>Clothing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.11' type='checkbox'  value='Housing'  id='choice_2_22_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_11' id='label_2_22_11' class='gform-field-label gform-field-label--type-inline'>Housing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.12' type='checkbox'  value='Utilities'  id='choice_2_22_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_12' id='label_2_22_12' class='gform-field-label gform-field-label--type-inline'>Utilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.13' type='checkbox'  value='Transportation'  id='choice_2_22_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_13' id='label_2_22_13' class='gform-field-label gform-field-label--type-inline'>Transportation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.14' type='checkbox'  value='Employment'  id='choice_2_22_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_14' id='label_2_22_14' class='gform-field-label gform-field-label--type-inline'>Employment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.15' type='checkbox'  value='Money management'  id='choice_2_22_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_15' id='label_2_22_15' class='gform-field-label gform-field-label--type-inline'>Money management<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.16' type='checkbox'  value='Parenting Information'  id='choice_2_22_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_16' id='label_2_22_16' class='gform-field-label gform-field-label--type-inline'>Parenting Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.17' type='checkbox'  value='Substance abuse information'  id='choice_2_22_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_17' id='label_2_22_17' class='gform-field-label gform-field-label--type-inline'>Substance abuse information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.18' type='checkbox'  value='Mental health information'  id='choice_2_22_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_18' id='label_2_22_18' class='gform-field-label gform-field-label--type-inline'>Mental health information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.19' type='checkbox'  value='Medical\/dental information'  id='choice_2_22_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_19' id='label_2_22_19' class='gform-field-label gform-field-label--type-inline'>Medical\/dental information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.21' type='checkbox'  value='Legal information'  id='choice_2_22_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_21' id='label_2_22_21' class='gform-field-label gform-field-label--type-inline'>Legal information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.22' type='checkbox'  value='Spiritual information'  id='choice_2_22_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_22' id='label_2_22_22' class='gform-field-label gform-field-label--type-inline'>Spiritual information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.23' type='checkbox'  value='Health\/hygiene information'  id='choice_2_22_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_23' id='label_2_22_23' class='gform-field-label gform-field-label--type-inline'>Health\/hygiene information<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Other Needs\/Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_2_27' class='textarea small'    placeholder='Other Needs\/Comments'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>How did you learn about us?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'    placeholder='How did you learn about us?'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>If referred by a community resource, please tell us the person&#039;s name who referred you, their organization, and their contact information:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'    placeholder='Please tell us the person&#039;s name who referred you, their organization, and their contact information.'  aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' 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