{"id":38449,"date":"2024-02-20T14:36:07","date_gmt":"2024-02-20T19:36:07","guid":{"rendered":"https:\/\/cnnc.uncg.edu\/?page_id=38449"},"modified":"2024-02-20T15:58:33","modified_gmt":"2024-02-20T20:58:33","slug":"community-centers-referral-form-3","status":"publish","type":"page","link":"https:\/\/cnnc.uncg.edu\/community-centers-program\/community-centers-referral-form-3\/","title":{"rendered":"Community Centers Referral Form"},"content":{"rendered":"\n<div class=\"wp-block-uncg-next-gen-blocks-wrapper uncg-block-wrapper\"><div class=\"uncg-wrapper-inner\" style=\"padding-top:24px;padding-bottom:24px;padding-right:24px;padding-left:24px\"><div class=\"uncg-wrapper-inner-content\">\n<p>To make a referral for case management or employment services, please complete the below form.  Alternatively, you may download the form <a href=\"https:\/\/cnnc.uncg.edu\/wp-content\/uploads\/2018\/07\/Community-Centers-Referral-Form.doc\">here<\/a> and submit it to Natacha Nikokeza via email at\u00a0<a href=\"mailto:n_nikoke@uncg.edu\">n_nikoke@uncg.edu<\/a>.<\/p>\n\n\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_7' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/wp-json\/wp\/v2\/pages\/38449' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_7_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Agency \/ Individual Referring Client<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_7_1'>\n                            \n                            \n                            \n                            <span id='input_7_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_7_1_6' class='gform-field-label gform-field-label--type-sub '>Full Name<\/label>\n                                                            <input type='text' name='input_1.6' id='input_7_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_7_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_4\" ><legend class='gfield_label gform-field-label' >Referral Date<\/legend><div id='input_7_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_7_4_1_container'><label for='input_7_4_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_4[]' id='input_7_4_1'   aria-required='false'  ><option value=''>Month<\/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='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_7_4_2_container'><label for='input_7_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_4[]' id='input_7_4_2'   aria-required='false'  ><option value=''>Day<\/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='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_7_4_3_container'><label for='input_7_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_4[]' id='input_7_4_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_7_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_5\" ><label class='gfield_label gform-field-label' for='input_7_5'>Staff Member Referring Client<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_7_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_6\" ><label class='gfield_label gform-field-label' for='input_7_6'>Full Name of Client or Family<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_7_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address of Client<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_7_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_7_1_container' >\n                                        <label for='input_7_7_1' id='input_7_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_7.1' id='input_7_7_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_7_2_container' >\n                                        <label for='input_7_7_2' id='input_7_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_7.2' id='input_7_7_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_7_3_container' >\n                                    <label for='input_7_7_3' id='input_7_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_7.3' id='input_7_7_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_7.4' id='input_7_7_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_7_5_container' >\n                                    <label for='input_7_7_5' id='input_7_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_7.5' id='input_7_7_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_7_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_7_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_8\" ><label class='gfield_label gform-field-label' for='input_7_8'>Preferred Spoken Language<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_7_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_9\" ><label class='gfield_label gform-field-label' for='input_7_9'>Client Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_7_9' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_2\" ><label class='gfield_label gform-field-label' for='input_7_2'>Client Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_7_2' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_7_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_11\" ><legend class='gfield_label gform-field-label' >Best Way to Contact Client<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_11'>\n\t\t\t<div class='gchoice gchoice_7_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Telephone'  id='choice_7_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_0' id='label_7_11_0' class='gform-field-label gform-field-label--type-inline'>Telephone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Email'  id='choice_7_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_1' id='label_7_11_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='gf_other_choice'  id='choice_7_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_2' id='label_7_11_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_7_11_other' class='gchoice_other_control' name='input_11_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_22\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_22\" ><label class='gfield_label gform-field-label' for='input_7_22'>Please submit one form of identification as applicable (If client is undocumented, please note in &quot;additional Information&quot;)<\/label><div class='gfield_description' id='gfield_description_7_22'>Examples: I-94; Parolee Stamp; Driver&#8217;s License; Green Card; State ID; FaithAction ID; Passport (expired or unexpired); EAD &#8211; Employment Authorization Document; National Identity Card; etc.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2146435072' \/><input name='input_22' id='input_7_22' type='file' class='large' aria-describedby=\"gfield_upload_rules_7_22 gfield_description_7_22\" onchange='javascript:gformValidateFileSize( this, 2146435072 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_7_22'>Max. file size: 2 GB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_7_22'><\/div><\/div><\/div><div id=\"field_7_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_12\" ><h3 class=\"gsection_title\">If Refugee \/ Asylee<\/h3><\/div><fieldset id=\"field_7_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_13\" ><legend class='gfield_label gform-field-label' >Client Date of Arrival<\/legend><div id='input_7_13' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_7_13_1_container'><label for='input_7_13_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_13[]' id='input_7_13_1'   aria-required='false'  ><option value=''>Month<\/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='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_7_13_2_container'><label for='input_7_13_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_13[]' id='input_7_13_2'   aria-required='false'  ><option value=''>Day<\/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='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_7_13_3_container'><label for='input_7_13_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_13[]' id='input_7_13_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_7_14\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_14\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Programs Client is Currently Enrolled in with Referring Agency<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Program<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Case Manager<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd 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style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_7_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_15\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_7_3\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_3\" ><label class='gfield_label gform-field-label' for='input_7_3'>Reason for referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_3' id='input_7_3' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_7_16\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_16\" ><label class='gfield_label gform-field-label' for='input_7_16'>Any additional information we need to know?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_7_16' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_18\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_18'>I, (client), provide (referring agency) consent to provide information regarding my case and services provided as it relates and is considered essential to the referral process and provision of services to be provided by the UNCG Center for New North Carolinians (CNNC) on my behalf. I reserve the right to revoke consent in writing at any time. I also reserve the right to request that certain information remain confidential. <\/div><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_7_18_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_18\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_18_1' >I provide consent for this agency to share information with CNNC.<\/label><input type='hidden' name='input_18.2' value='I provide consent for this agency to share information with CNNC.' class='gform_hidden' \/><input type='hidden' name='input_18.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_7_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-three-quarter field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_19\" ><label 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