Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please use this form to refer asylum seekers and other humanitarian migrants to Global Refuge case management programs in the following locations: Baltimore, MD San Antonio, TX</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_ReferralSource_Ref" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Referring Organization</label><input name="CST_1" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_ReferringWorker_Ref"><i class="fa fa-font"></i><label class="er_fld_label">Referring Worker Name</label><input name="CST_13" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref"><i class="fa fa-font"></i><label class="er_fld_label">Referring Worker Phone Number</label><input name="CST_14" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CustomField_Value_3"><i class="fa fa-font"></i><label class="er_fld_label">Referring Worker Email</label><input name="CST_20" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Primary Client Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_First"><i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Name_Last"><i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_6" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CC_Phone_Home"><i class="fa fa-font"></i><label class="er_fld_label required">Home/Sponsor Phone</label><input name="CST_16" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CustomField_Value_6"><i class="fa fa-font"></i><label class="er_fld_label">Additional Phone</label><input name="CST_19" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="Country_UNID"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Country of Origin</label><select name="CST_7" class="er_fld_required er_fld_width75"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Afghanistan">Afghanistan</option><option value="Akrotiri">Akrotiri</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antarctica">Antarctica</option><option value="Antigua">Antigua</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Ashmore and Cartier Islands">Ashmore and Cartier Islands</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="Bahamas">Bahamas</option><option value="Bahrain">Bahrain</option><option value="Baker Island">Baker Island</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Bassas Da India">Bassas Da India</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bonaire, Sint Eustatius, and Saba">Bonaire, Sint Eustatius, and Saba</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Bouvert Island">Bouvert Island</option><option value="Brazil">Brazil</option><option value="British Indian Ocean Territory">British Indian Ocean Territory</option><option value="British Virgin Islands">British Virgin Islands</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso (UVolta)">Burkina Faso (UVolta)</option><option value="Burundi">Burundi</option><option value="Cabo Verde">Cabo Verde</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Christmas Island">Christmas Island</option><option value="Clipperton Island">Clipperton Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoro Islands">Comoro Islands</option><option value="Cook Islands">Cook Islands</option><option value="Coral Sea Islands">Coral Sea Islands</option><option value="Costa Rica">Costa Rica</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Curacao">Curacao</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Dem. Rep. Congo">Dem. Rep. Congo</option><option value="Denmark">Denmark</option><option value="Dhekelia">Dhekelia</option><option value="Diego Garcia">Diego Garcia</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="East Timor">East Timor</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Ethiopia">Ethiopia</option><option value="Europa Island">Europa Island</option><option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Guiana">French Guiana</option><option value="French Polynesia">French Polynesia</option><option value="French Southern and Antarctic Lands">French Southern and Antarctic Lands</option><option value="Gabon">Gabon</option><option value="Gaza Strip">Gaza Strip</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Glorioso Islands">Glorioso Islands</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea - Bissau">Guinea - Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Heard Islands and McDonald Islands">Heard Islands and McDonald Islands</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Howland Island">Howland Island</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Ivory Coast">Ivory Coast</option><option value="Jamaica">Jamaica</option><option value="Jan Mayen">Jan Mayen</option><option value="Japan (also Ryukyu Islands - North)">Japan (also Ryukyu Islands - North)</option><option value="Jarvis Island">Jarvis Island</option><option value="Jersey">Jersey</option><option value="Johnston Atoll">Johnston Atoll</option><option value="Jordan">Jordan</option><option value="Juan De Nova Island">Juan De Nova Island</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kingman Reef">Kingman Reef</option><option value="Kiribati">Kiribati</option><option value="Korea, North">Korea, North</option><option value="Korea, Republic of South">Korea, Republic of South</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar (Malagasy Republic)">Madagascar (Malagasy Republic)</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Man, Isle of">Man, Isle of</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Midway Islands">Midway Islands</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar (Burma)">Myanmar (Burma)</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Navassa Island">Navassa Island</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="Netherlands Antilles">Netherlands Antilles</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Palmyra Atoll">Palmyra Atoll</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paracel Islands">Paracel Islands</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Republic of the Congo">Republic of the Congo</option><option value="Reunion">Reunion</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Martin">Saint Martin</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Sint Maarten">Sint Maarten</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="South Africa">South Africa</option><option value="South Georgia and South Sandwich Islands">South Georgia and South Sandwich Islands</option><option value="South Sudan">South Sudan</option><option value="Spain">Spain</option><option value="Spratly Islands">Spratly Islands</option><option value="Sri Lanka (Ceylon)">Sri Lanka (Ceylon)</option><option value="Stateless Citizenship">Stateless Citizenship</option><option value="St. Helena">St. Helena</option><option value="St. Kitts and Nevis">St. Kitts and Nevis</option><option value="St. Lucia">St. Lucia</option><option value="St. Pierre and Miquelon">St. Pierre and Miquelon</option><option value="St. Vincent and The Grenadines">St. Vincent and The Grenadines</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Swaziland">Swaziland</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="The Gambia">The Gambia</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tromelin Island">Tromelin Island</option><option value="Trust Territory of the Pacific Islands">Trust Territory of the Pacific Islands</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="Union of Soviet Socialist Republics">Union of Soviet Socialist Republics</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="United States of America">United States of America</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="Virgin Islands">Virgin Islands</option><option value="Wake Island">Wake Island</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Washington Proc Ctr">Washington Proc Ctr</option><option value="West Bank">West Bank</option><option value="Western Sahara">Western Sahara</option><option value="Western Samoa">Western Samoa</option><option value="Yemen">Yemen</option><option value="Yugoslavia">Yugoslavia</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="Unknown">Unknown</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Language"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Primary Language</label><select name="CST_21" class="er_fld_required er_fld_width75"><option value="Unknown" selected="">Unknown</option><option value="Acehnese">Acehnese</option><option value="Acholi">Acholi</option><option value="Ado">Ado</option><option value="Afar">Afar</option><option value="Afrikaans">Afrikaans</option><option value="Akan">Akan</option><option value="Albanian (Arbëreshë)">Albanian (Arbëreshë)</option><option value="Albanian (Arvanitika)">Albanian (Arvanitika)</option><option value="Albanian (Gheg)">Albanian (Gheg)</option><option value="Albanian (Tosk)">Albanian (Tosk)</option><option value="Aluru">Aluru</option><option value="Amharic">Amharic</option><option value="Angolan">Angolan</option><option value="Ankole">Ankole</option><option value="Anuak">Anuak</option><option value="Arabic">Arabic</option><option value="Arabic (Sudanese Spoken)">Arabic (Sudanese Spoken)</option><option value="Arakan ">Arakan </option><option value="Armenian">Armenian</option><option value="Assamese">Assamese</option><option value="Assyrian">Assyrian</option><option value="Awadhi">Awadhi</option><option value="Azerbaijani (Azeri)">Azerbaijani (Azeri)</option><option value="Azerbaijani (North)">Azerbaijani (North)</option><option value="Azzande">Azzande</option><option value="Bambara">Bambara</option><option value="Bani-Halba">Bani-Halba</option><option value="Banjuni">Banjuni</option><option value="Bantu">Bantu</option><option value="Barawan">Barawan</option><option value="Bargo">Bargo</option><option value="Bari">Bari</option><option value="Bassa">Bassa</option><option value="Behdini">Behdini</option><option value="Belarusan">Belarusan</option><option value="Belin">Belin</option><option value="Bemba">Bemba</option><option value="Benadir">Benadir</option><option value="Bengali">Bengali</option><option value="Berti">Berti</option><option value="Bhojpuri">Bhojpuri</option><option value="Bilen">Bilen</option><option value="Bosnian">Bosnian</option><option value="Bual Khaw">Bual Khaw</option><option value="Bulgarian">Bulgarian</option><option value="Burmese">Burmese</option><option value="Cebuano">Cebuano</option><option value="Chaldean">Chaldean</option><option value="Chechen">Chechen</option><option value="Chhattisgarhi">Chhattisgarhi</option><option value="Chichiwa">Chichiwa</option><option value="CHIN">CHIN</option><option value="Chin - Dai">Chin - Dai</option><option value="Chin – Falam">Chin – Falam</option><option value="Chin - Kanpelet">Chin - Kanpelet</option><option value="Chin – Khumi">Chin – Khumi</option><option value="Chin – Matu">Chin – Matu</option><option value="Chin – Mindat">Chin – Mindat</option><option value="Chin – Mizo">Chin – Mizo</option><option value="Chin – Senthang">Chin – Senthang</option><option value="Chin – Siyin">Chin – Siyin</option><option value="Chin – Thado">Chin – Thado</option><option value="Chin – Zaniat">Chin – Zaniat</option><option value="Chin – Zokhua">Chin – Zokhua</option><option value="CHIN LAI">CHIN LAI</option><option value="Chinese (Gan)">Chinese (Gan)</option><option value="Chinese (Hakka)">Chinese (Hakka)</option><option value="Chinese (Jinyu)">Chinese (Jinyu)</option><option value="Chinese (Mandarin)">Chinese (Mandarin)</option><option value="Chinese (Min Bei)">Chinese (Min Bei)</option><option value="Chinese (Min Nan)">Chinese (Min Nan)</option><option value="Chinese (Wu)">Chinese (Wu)</option><option value="Chinese (Xiang)">Chinese (Xiang)</option><option value="Chinese (Yue)">Chinese (Yue)</option><option value="Chittagonian">Chittagonian</option><option value="Circassian (Syrian Spoken)">Circassian (Syrian Spoken)</option><option value="Creole (Guyanese Creole English)">Creole (Guyanese Creole English)</option><option value="Creole (Haitian Creole French)">Creole (Haitian Creole French)</option><option value="Creole (Lesser Antillean Creole French)">Creole (Lesser Antillean Creole French)</option><option value="Creole (Sierra Leonean Creole English)">Creole (Sierra Leonean Creole English)</option><option value="Creole (Southwestern Caribbean Creole English)">Creole (Southwestern Caribbean Creole English)</option><option value="Croatian">Croatian</option><option value="Czech">Czech</option><option value="Dadjo">Dadjo</option><option value="Dari">Dari</option><option value="Daroud">Daroud</option><option value="Deccan">Deccan</option><option value="Didinga">Didinga</option><option value="Dinka">Dinka</option><option value="Dutch">Dutch</option><option value="Dzongka">Dzongka</option><option value="East Pwo">East Pwo</option><option value="Ede">Ede</option><option value="Eleme">Eleme</option><option value="English">English</option><option value="Erenga">Erenga</option><option value="Ewe">Ewe</option><option value="Falam">Falam</option><option value="Farsi">Farsi</option><option value="Farsi (Eastern)">Farsi (Eastern)</option><option value="Farsi (Western)">Farsi (Western)</option><option value="Fejelu">Fejelu</option><option value="Foor">Foor</option><option value="French">French</option><option value="Fula">Fula</option><option value="Fulani">Fulani</option><option value="Fulbe">Fulbe</option><option value="Fulfulde">Fulfulde</option><option value="Fur">Fur</option><option value="Gagauz">Gagauz</option><option value="Georgian">Georgian</option><option value="German (Standard)">German (Standard)</option><option value="Gio">Gio</option><option value="Gokana">Gokana</option><option value="Gola">Gola</option><option value="Grebo">Grebo</option><option value="Greek">Greek</option><option value="Gujarati">Gujarati</option><option value="Hainanese">Hainanese</option><option value="Hakha - Chin Burmese dialect">Hakha - Chin Burmese dialect</option><option value="Haryanvi">Haryanvi</option><option value="Hausa">Hausa</option><option value="Hazaragi">Hazaragi</option><option value="Hebrew">Hebrew</option><option value="Hema">Hema</option><option value="Hiligaynon">Hiligaynon</option><option value="Hindi">Hindi</option><option value="Hmong">Hmong</option><option value="Hokkien">Hokkien</option><option value="Hunde">Hunde</option><option value="Hungarian">Hungarian</option><option value="Igbo">Igbo</option><option value="Ilocano">Ilocano</option><option value="Indonesian">Indonesian</option><option value="Italian">Italian</option><option value="Japanese">Japanese</option><option value="Jarai">Jarai</option><option value="Javanese">Javanese</option><option value="Kaba">Kaba</option><option value="Kachin ">Kachin </option><option value="Kachin - Jingpaw">Kachin - Jingpaw</option><option value="Kachin - Lisu">Kachin - Lisu</option><option value="Kachin - Rawang">Kachin - Rawang</option><option value="Kakwa">Kakwa</option><option value="Kannada">Kannada</option><option value="Karen">Karen</option><option value="Karenni - Kayah">Karenni - Kayah</option><option value="Karenni - Kayan">Karenni - Kayan</option><option value="Karenni - Kayaw">Karenni - Kayaw</option><option value="Kazakh">Kazakh</option><option value="Khana">Khana</option><option value="Khmer">Khmer</option><option value="Kibembe">Kibembe</option><option value="Kifulero">Kifulero</option><option value="Kiganda">Kiganda</option><option value="Kigisu">Kigisu</option><option value="Kiha">Kiha</option><option value="Kikongo">Kikongo</option><option value="Kikuyu">Kikuyu</option><option value="Kinande">Kinande</option><option value="Kinyabwisha">Kinyabwisha</option><option value="Kinyamulenge">Kinyamulenge</option><option value="Kinyarwanda">Kinyarwanda</option><option value="Kirundi">Kirundi</option><option value="Kishi">Kishi</option><option value="Kissi">Kissi</option><option value="Kiswahili">Kiswahili</option><option value="Kiteso">Kiteso</option><option value="Kivira">Kivira</option><option value="Kizigua">Kizigua</option><option value="Koniaka">Koniaka</option><option value="Korean">Korean</option><option value="Kpelle">Kpelle</option><option value="Krahn">Krahn</option><option value="Krio">Krio</option><option value="Kru">Kru</option><option value="Kuku">Kuku</option><option value="Kunama">Kunama</option><option value="Kuranko">Kuranko</option><option value="Kurdi">Kurdi</option><option value="Kurmanji">Kurmanji</option><option value="Kwakwa">Kwakwa</option><option value="Kyrgyz">Kyrgyz</option><option value="Lai ">Lai </option><option value="LAI - Achi">LAI - Achi</option><option value="LAI - Akateco">LAI - Akateco</option><option value="LAI - Amuzgo ">LAI - Amuzgo </option><option value="LAI - Awaketek">LAI - Awaketek</option><option value="LAI - Chatino">LAI - Chatino</option><option value="LAI - Chinantec ">LAI - Chinantec </option><option value="LAI - Ch'ol ">LAI - Ch'ol </option><option value="LAI - Chontal de Tabasco ">LAI - Chontal de Tabasco </option><option value="LAI - Chʼorti">LAI - Chʼorti</option><option value="LAI - Chuj">LAI - Chuj</option><option value="LAI - Garifuna">LAI - Garifuna</option><option value="LAI - Huastec ">LAI - Huastec </option><option value="LAI - Huichol">LAI - Huichol</option><option value="LAI - Itzaʼ">LAI - Itzaʼ</option><option value="LAI - Ixil">LAI - Ixil</option><option value="LAI - Jakaltek">LAI - Jakaltek</option><option value="LAI - Kaqchikel">LAI - Kaqchikel</option><option value="LAI - Kʼicheʼ">LAI - Kʼicheʼ</option><option value="LAI - Mam">LAI - Mam</option><option value="LAI - Mazahua ">LAI - Mazahua </option><option value="LAI - Mazatec ">LAI - Mazatec </option><option value="LAI - Mixe ">LAI - Mixe </option><option value="LAI - Mixteco">LAI - Mixteco</option><option value="LAI - Mopan">LAI - Mopan</option><option value="LAI - Otomi">LAI - Otomi</option><option value="LAI - Popoluca ">LAI - Popoluca </option><option value="LAI - Poqomam">LAI - Poqomam</option><option value="LAI - Poqomchiʼ">LAI - Poqomchiʼ</option><option value="LAI - Purépecha">LAI - Purépecha</option><option value="LAI - Qʼanjobʼal">LAI - Qʼanjobʼal</option><option value="LAI - Qʼeqchiʼ">LAI - Qʼeqchiʼ</option><option value="LAI - Quechua">LAI - Quechua</option><option value="LAI - Quichua">LAI - Quichua</option><option value="LAI - Sakapultek">LAI - Sakapultek</option><option value="LAI - Sipakapense">LAI - Sipakapense</option><option value="LAI - Tarahumara">LAI - Tarahumara</option><option value="LAI - Tektitek">LAI - Tektitek</option><option value="LAI - Tlapanec ">LAI - Tlapanec </option><option value="LAI - Tojolab'al">LAI - Tojolab'al</option><option value="LAI - Totonac ">LAI - Totonac </option><option value="LAI - Tzʼutujil">LAI - Tzʼutujil</option><option value="LAI - Uspantek">LAI - Uspantek</option><option value="LAI - Xinca">LAI - Xinca</option><option value="LAI - Yucatec Maya">LAI - Yucatec Maya</option><option value="LAI - Zapoteco">LAI - Zapoteco</option><option value="Lao">Lao</option><option value="Lari">Lari</option><option value="Lautu ">Lautu </option><option value="Liberian English">Liberian English</option><option value="Limba">Limba</option><option value="Lingala">Lingala</option><option value="Logbara">Logbara</option><option value="Loma">Loma</option><option value="Lombard">Lombard</option><option value="LORI">LORI</option><option value="Lotuko">Lotuko</option><option value="Luba Kasai">Luba Kasai</option><option value="Luganda">Luganda</option><option value="Mabani">Mabani</option><option value="Macedonian">Macedonian</option><option value="Madi">Madi</option><option value="Madura">Madura</option><option value="Magahi">Magahi</option><option value="Maimai">Maimai</option><option value="Maithili">Maithili</option><option value="Malagasy">Malagasy</option><option value="Malay">Malay</option><option value="Malayalam">Malayalam</option><option value="Mandean">Mandean</option><option value="Mandingo">Mandingo</option><option value="Mano">Mano</option><option value="Mara ">Mara </option><option value="Mararit">Mararit</option><option value="Marathi">Marathi</option><option value="Marwari">Marwari</option><option value="Mashi">Mashi</option><option value="Massalit">Massalit</option><option value="Matu">Matu</option><option value="Mende">Mende</option><option value="Mi-E">Mi-E</option><option value="Mina">Mina</option><option value="Mizo (Lushai)">Mizo (Lushai)</option><option value="Mon">Mon</option><option value="Mongolian">Mongolian</option><option value="Monokutuba">Monokutuba</option><option value="Moro">Moro</option><option value="Napoletano-Calabrese">Napoletano-Calabrese</option><option value="Nepali">Nepali</option><option value="Ngawn">Ngawn</option><option value="Ngonbe">Ngonbe</option><option value="Nuba">Nuba</option><option value="Nuer">Nuer</option><option value="Numpoh">Numpoh</option><option value="Ogoni">Ogoni</option><option value="Oriya">Oriya</option><option value="Oromo (West Central)">Oromo (West Central)</option><option value="Pakhtu">Pakhtu</option><option value="Panjabi">Panjabi</option><option value="Panjabi (Eastern)">Panjabi (Eastern)</option><option value="Panjabi (Western)">Panjabi (Western)</option><option value="Parte">Parte</option><option value="Pashto">Pashto</option><option value="Pashto (Central)">Pashto (Central)</option><option value="Pashto (Northern)">Pashto (Northern)</option><option value="Pashto (Southern)">Pashto (Southern)</option><option value="Phnong">Phnong</option><option value="Pojulu">Pojulu</option><option value="Polish">Polish</option><option value="Portuguese">Portuguese</option><option value="Putu">Putu</option><option value="Pwo Karen">Pwo Karen</option><option value="Rahaweyn">Rahaweyn</option><option value="Rawang">Rawang</option><option value="Rega Lega">Rega Lega</option><option value="Rohingya">Rohingya</option><option value="Romanian">Romanian</option><option value="Romano-Serbian">Romano-Serbian</option><option value="Russian">Russian</option><option value="Rwanda">Rwanda</option><option value="Saho">Saho</option><option value="Salamat">Salamat</option><option value="Sango">Sango</option><option value="Saraiki">Saraiki</option><option value="Sarpo">Sarpo</option><option value="Serbian">Serbian</option><option value="Sesotho">Sesotho</option><option value="Setswana">Setswana</option><option value="Sgaw Karen">Sgaw Karen</option><option value="Shan ">Shan </option><option value="Shikaki">Shikaki</option><option value="Shilluk">Shilluk</option><option value="Shona">Shona</option><option value="Sidamo">Sidamo</option><option value="Sifwe">Sifwe</option><option value="Sign Language">Sign Language</option><option value="Sindhi">Sindhi</option><option value="Sinhala">Sinhala</option><option value="Siryac">Siryac</option><option value="Siswati">Siswati</option><option value="Siyin">Siyin</option><option value="Slovenian">Slovenian</option><option value="Somali">Somali</option><option value="Sorani">Sorani</option><option value="Spanish">Spanish</option><option value="Srilankan">Srilankan</option><option value="Sunda">Sunda</option><option value="Surchi">Surchi</option><option value="Swedish">Swedish</option><option value="Tae Chiew">Tae Chiew</option><option value="Tagalog">Tagalog</option><option value="Tajiki">Tajiki</option><option value="Tamil">Tamil</option><option value="Tapong">Tapong</option><option value="Tatar">Tatar</option><option value="Tedim ">Tedim </option><option value="Telugu">Telugu</option><option value="Temne">Temne</option><option value="Tennet">Tennet</option><option value="Thai">Thai</option><option value="Thai (Northeastern)">Thai (Northeastern)</option><option value="Tibetan">Tibetan</option><option value="Tigray">Tigray</option><option value="Tigrigwa">Tigrigwa</option><option value="Tigrinya">Tigrinya</option><option value="Tribal">Tribal</option><option value="Tshiluba">Tshiluba</option><option value="Tunjur">Tunjur</option><option value="Turk (Iranian)">Turk (Iranian)</option><option value="Turkish">Turkish</option><option value="Turkman">Turkman</option><option value="Twa">Twa</option><option value="Ukrainian">Ukrainian</option><option value="Urdu">Urdu</option><option value="Uyghur">Uyghur</option><option value="Uzbek">Uzbek</option><option value="Vai">Vai</option><option value="Vietnamese">Vietnamese</option><option value="Yakoma">Yakoma</option><option value="Yiddish">Yiddish</option><option value="Yoruba">Yoruba</option><option value="Zaghawa">Zaghawa</option><option value="Zhuang (Northern)">Zhuang (Northern)</option><option value="Zo ">Zo </option><option value="Zophei ">Zophei </option><option value="Zotung ">Zotung </option><option value="Zulu">Zulu</option></select></li><li class="er_fld_type_dropdown sortable-chosen" draggable="true" style="width: 25%;" map_to="CustomField_Value_1"><i class="fa fa-caret-down"></i><label class="er_fld_label required"># of Adults in Family</label><select name="CST_10" class="er_fld_required er_fld_width75"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="0">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="Unknown">Unknown</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CustomField_Value_2"><i class="fa fa-caret-down"></i><label class="er_fld_label required"># of Dependent Children in Family</label><select name="CST_15" class="er_fld_required er_fld_width75"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="0">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="Unknown">Unknown</option></select></li><li class="er_fld_type_text sortable-chosen" draggable="true" style="width: 25%;" map_to="CC_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">Destination City</label><input name="CST_8" type="text" class="er_fld_required er_fld_width75"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="CC_Address_State"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Destination State</label><select name="CST_23" class="er_fld_required er_fld_width75"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama ">Alabama </option><option value="Alaska ">Alaska </option><option value="Arizona ">Arizona </option><option value="Arkansas ">Arkansas </option><option value="California ">California </option><option value="Colorado ">Colorado </option><option value="Connecticut ">Connecticut </option><option value="Delaware ">Delaware </option><option value="Florida ">Florida </option><option value="Georgia ">Georgia </option><option value="Hawaii ">Hawaii </option><option value="Idaho ">Idaho </option><option value="Illinois ">Illinois </option><option value="Indiana ">Indiana </option><option value="Iowa ">Iowa </option><option value="Kansas ">Kansas </option><option value="Kentucky ">Kentucky </option><option value="Louisiana ">Louisiana </option><option value="Maine ">Maine </option><option value="Maryland ">Maryland </option><option value="Massachusetts ">Massachusetts </option><option value="Michigan ">Michigan </option><option value="Minnesota ">Minnesota </option><option value="Mississippi ">Mississippi </option><option value="Missouri ">Missouri </option><option value="Montana Nebraska ">Montana Nebraska </option><option value="Nevada ">Nevada </option><option value="New Hampshire ">New Hampshire </option><option value="New Jersey ">New Jersey </option><option value="New Mexico ">New Mexico </option><option value="New York ">New York </option><option value="North Carolina ">North Carolina </option><option value="North Dakota ">North Dakota </option><option value="Ohio ">Ohio </option><option value="Oklahoma ">Oklahoma </option><option value="Oregon ">Oregon </option><option value="Pennsylvania Rhode Island ">Pennsylvania Rhode Island </option><option value="South Carolina ">South Carolina </option><option value="South Dakota ">South Dakota </option><option value="Tennessee ">Tennessee </option><option value="Texas ">Texas </option><option value="Utah ">Utah </option><option value="Vermont ">Vermont </option><option value="Virginia ">Virginia </option><option value="Washington ">Washington </option><option value="West Virginia ">West Virginia </option><option value="Wisconsin ">Wisconsin </option><option value="Wyoming">Wyoming</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label">If known, please describe if family member(s) have urgent service needs (ex. medical/mental health/basic necessities such as food/clothes/housing)</label><textarea name="CST_24" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" map_to="CustomField_Value_7"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Privacy and Confidentiality Acknowledgement</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_25" value="I affirm that the client is aware the above information will be shared with Global Refuge and its affiliate agencies for the purposes of providing them case management services near their current residence. The client has verbally consented to let me share this information with Global Refuge. ">I affirm that the client is aware the above information will be shared with Global Refuge and its affiliate agencies for the purposes of providing them case management services near their current residence. The client has verbally consented to let me share this information with Global Refuge. </label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_25" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_25_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_selected" draggable="false"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">If the client has not consented to their information being shared with Global Refuge, please DO NOT submit the referral. </div></li></ul>
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