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class="menu fl-menu-horizontal fl-toggle-arrows"><li id="menu-item-86" class="menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children fl-has-submenu"><div class="fl-has-submenu-container"><a href="/our-mission">Mission</a><span class="fl-menu-toggle"></span></div><ul class="sub-menu"> <li id="menu-item-78" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://a2ndcup.com/our-mission/">Our Mission</a></li> <li id="menu-item-7238" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://a2ndcup.com/ourvalues/">Our Values</a></li> <li id="menu-item-62" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://a2ndcup.com/about-trafficking/">About Trafficking</a></li> <li id="menu-item-81" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://a2ndcup.com/resources/">Resources</a></li> <li id="menu-item-6490" class="menu-item menu-item-type-post_type 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class="fl-menu-cart-icon fal fa-shopping-cart" role="img" aria-label="Cart"></i><span class="fl-menu-cart-count">0 items</span></a></li></ul></nav></div> </div> </header> </div> </div> </div> </div> </div> </div> </header><div class="uabb-js-breakpoint" style="display: none;"></div><div class="site-inner"><div class="content-sidebar-wrap"><main class="content" id="genesis-content"><article class="post-3917 page type-page status-publish entry" aria-label="Brazen Table Foundations Participant Referral Form"><header class="entry-header"></header><div class="entry-content"><div class="fl-builder-content fl-builder-content-3917 fl-builder-content-primary fl-builder-global-templates-locked" data-post-id="3917"><div class="fl-row fl-row-full-width fl-row-bg-photo fl-node-5fc531369af1b fl-row-custom-height fl-row-align-center fl-row-bg-overlay fl-animation fl-fade-in" data-node="5fc531369af1b" data-animation-delay="0" data-animation-duration="0.75"> <div class="fl-row-content-wrap"> <div class="fl-row-content fl-row-fixed-width fl-node-content"> <div class="fl-col-group fl-node-5fc531369af13" data-node="5fc531369af13"> <div class="fl-col fl-node-5fc531369af16" data-node="5fc531369af16"> <div class="fl-col-content fl-node-content"><div class="fl-module fl-module-photo fl-node-5fc531794a629" data-node="5fc531794a629"> <div class="fl-module-content fl-node-content"> <div class="fl-photo fl-photo-align-center" itemscope itemtype="https://schema.org/ImageObject"> <div class="fl-photo-content fl-photo-img-png"> <img decoding="async" fetchpriority="high" class="fl-photo-img wp-image-359 size-medium" src="https://a2ndcup.com/wp-content/uploads/logo-brazen-table-800x480.png" alt="Brazen Table" itemprop="image" height="480" width="800" title="logo-brazen-table" srcset="https://a2ndcup.com/wp-content/uploads/logo-brazen-table-800x480.png 800w, https://a2ndcup.com/wp-content/uploads/logo-brazen-table-1440x864.png 1440w, https://a2ndcup.com/wp-content/uploads/logo-brazen-table-768x461.png 768w, https://a2ndcup.com/wp-content/uploads/logo-brazen-table-600x360.png 600w, https://a2ndcup.com/wp-content/uploads/logo-brazen-table.png 1500w" sizes="(max-width: 800px) 100vw, 800px" /> </div> </div> </div> </div> <div class="fl-module fl-module-heading fl-node-5fc531369af18" data-node="5fc531369af18"> <div class="fl-module-content fl-node-content"> <h1 class="fl-heading"> <span class="fl-heading-text">Foundations Program</span> </h1> </div> </div> <div class="fl-module fl-module-heading fl-node-5fc5316774024" data-node="5fc5316774024"> <div class="fl-module-content fl-node-content"> <h2 class="fl-heading"> <span class="fl-heading-text">Referral Form</span> </h2> </div> </div> </div> </div> </div> </div> </div> </div> <div class="fl-row fl-row-full-width fl-row-bg-color fl-node-5fc531fa91a34 fl-row-default-height fl-row-align-center" data-node="5fc531fa91a34"> <div class="fl-row-content-wrap"> <div class="fl-row-content fl-row-fixed-width fl-node-content"> <div class="fl-col-group fl-node-5fc531fa942f4" data-node="5fc531fa942f4"> <div class="fl-col fl-node-5fc531fa9438b" data-node="5fc531fa9438b"> <div class="fl-col-content fl-node-content"><div class="fl-module fl-module-rich-text fl-node-5fc553863c6ea" data-node="5fc553863c6ea"> <div class="fl-module-content fl-node-content"> <div class="fl-rich-text"> <p>Thank you for taking the time to refer your client to the Brazen Table virtual program. We look forward to reviewing their application and your referral form.</p> </div> </div> </div> <div class="fl-module fl-module-html fl-node-5fc53212a73f1" data-node="5fc53212a73f1"> <div class="fl-module-content fl-node-content"> <div class="fl-html"> <div class="frm_forms with_frm_style frm_center_submit frm_style_formidable-style" id="frm_form_11_container" > <form enctype="multipart/form-data" method="post" class="frm-show-form frm_ajax_submit frm_pro_form " id="form_brazentable-foundationsvirtualprogrammingparticipantreferralformf3377613a8" > <div class="frm_form_fields "> <fieldset> <legend class="frm_screen_reader">Brazen Table - Foundations Participant Referral Form</legend> <div class="frm_fields_container"> <input type="hidden" name="frm_action" value="create" /> <input type="hidden" name="form_id" value="11" /> <input type="hidden" name="frm_hide_fields_11" id="frm_hide_fields_11" value="" /> <input type="hidden" name="form_key" value="brazentable-foundationsvirtualprogrammingparticipantreferralformf3377613a8" /> <input type="hidden" name="item_meta[0]" value="" /> <input type="hidden" id="frm_submit_entry_11" name="frm_submit_entry_11" value="dfce7e8246" /><input type="hidden" name="_wp_http_referer" value="/brazen-table/foundations-participant-referral-form/" /><div id="frm_field_67_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_r030k" id="field_r030k_label" class="frm_primary_label">Date <span class="frm_required">*</span> </label> <input type="text" id="field_r030k" name="item_meta[67]" value="09/27/2023" data-frmval="09/27/2023" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_68_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_zt8s5" id="field_zt8s5_label" class="frm_primary_label">Agency Name <span class="frm_required">*</span> </label> <input type="text" id="field_zt8s5" name="item_meta[68]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_69_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_h9gzi" id="field_h9gzi_label" class="frm_primary_label">Contact Name <span class="frm_required">*</span> </label> <input type="text" id="field_h9gzi" name="item_meta[69]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_552_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_iisrv" id="field_iisrv_label" class="frm_primary_label">Contact Title <span class="frm_required">*</span> </label> <input type="text" id="field_iisrv" name="item_meta[552]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_70_container" class="frm_form_field form-field frm_required_field frm_top_container frm_first frm_half"> <label for="field_wsaf3" id="field_wsaf3_label" class="frm_primary_label">Email Address <span class="frm_required">*</span> </label> <input type="email" id="field_wsaf3" name="item_meta[70]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Email is invalid" aria-invalid="false" /> </div> <div id="frm_field_71_container" class="frm_form_field form-field frm_required_field frm_top_container frm_half"> <label for="field_ju4hj" id="field_ju4hj_label" class="frm_primary_label">Phone <span class="frm_required">*</span> </label> <input type="tel" id="field_ju4hj" name="item_meta[71]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Phone is invalid" aria-invalid="false" pattern="((\+\d{1,3}(-|.| )?\(?\d\)?(-| |.)?\d{1,5})|(\(?\d{2,6}\)?))(-|.| )?(\d{3,4})(-|.| )?(\d{4})(( x| ext)\d{1,5}){0,1}$" /> </div> <div id="frm_field_72_container" class="frm_form_field form-field frm_required_field frm_top_container"> <div id="field_au0ow_label" class="frm_primary_label">Address <span class="frm_required">*</span> </div> <fieldset aria-labelledby="field_au0ow_label"> <legend class="frm_screen_reader frm_hidden"> Address</legend> <div class="frm_combo_inputs_container"> <div id="frm_field_72-line1_container" class="frm_form_field form-field "> <label for="field_au0ow_line1" class="frm_screen_reader frm_hidden"> Address </label> <input type="text" id="field_au0ow_line1" value="" name="item_meta[72][line1]" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-line1" /> </div> <div id="frm_field_72-line2_container" class="frm_form_field form-field "> <label for="field_au0ow_line2" class="frm_screen_reader frm_hidden"> Address </label> <input type="text" id="field_au0ow_line2" value="" name="item_meta[72][line2]" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Address is invalid" class="frm_optional" aria-invalid="false" autocomplete="address-line2" /> </div> <div id="frm_field_72-city_container" class="frm_form_field form-field frm_third frm_first"> <label for="field_au0ow_city" class="frm_screen_reader frm_hidden"> City </label> <input type="text" id="field_au0ow_city" value="" name="item_meta[72][city]" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level2" /> <div class="frm_description">City</div></div> <div id="frm_field_72-state_container" class="frm_form_field form-field frm_third"> <label for="field_au0ow_state" class="frm_screen_reader frm_hidden"> State/Province </label> <select name="item_meta[72][state]" id="field_au0ow_state" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="address-level1"> <option value=""> </option> <option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arkansas">Arkansas</option><option value="Arizona">Arizona</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District of Columbia">District of Columbia</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">Montana</option><option value="Nebraska">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">Pennsylvania</option><option value="Rhode Island">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> <div class="frm_description">State/Province</div></div> <div id="frm_field_72-zip_container" class="frm_form_field form-field frm_third"> <label for="field_au0ow_zip" class="frm_screen_reader frm_hidden"> Zip/Postal </label> <input type="text" id="field_au0ow_zip" value="" name="item_meta[72][zip]" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Address is invalid" aria-invalid="false" autocomplete="postal-code" /> <div class="frm_description">Zip/Postal</div></div> </div> </fieldset> </div> <div id="frm_field_73_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_u3d7a" id="field_u3d7a_label" class="frm_primary_label">Name of Client Being Referred <span class="frm_required">*</span> </label> <input type="text" id="field_u3d7a" name="item_meta[73]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_75_container" class="frm_form_field frm_html_container form-field"> <p style="margin-top: 2em; margin-bottom: 0;">Check off any circumstances (past or present) experienced by this client:</p> </div> <div id="frm_field_74_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_106cs_label" class="frm_primary_label">Sex trafficking or exploitation <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_106cs_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_74-0"><label for="field_106cs-0"><input type="checkbox" name="item_meta[74][]" id="field_106cs-0" value="Past" data-invmsg="Sex trafficking or exploitation is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_74-1"><label for="field_106cs-1"><input type="checkbox" name="item_meta[74][]" id="field_106cs-1" value="Present" data-invmsg="Sex trafficking or exploitation is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_76_container" class="frm_form_field form-field frm_top_container frm12 frm_first horizontal_radio"> <div id="field_l7o1r_label" class="frm_primary_label">Labor trafficking or exploitation <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_l7o1r_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_76-0"><label for="field_l7o1r-0"><input type="checkbox" name="item_meta[76][]" id="field_l7o1r-0" value="Past" data-invmsg="Labor trafficking or exploitation is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_76-1"><label for="field_l7o1r-1"><input type="checkbox" name="item_meta[76][]" id="field_l7o1r-1" value="Present" data-invmsg="Labor trafficking or exploitation is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_77_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_wogkw_label" class="frm_primary_label">Gaps in education <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_wogkw_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_77-0"><label for="field_wogkw-0"><input type="checkbox" name="item_meta[77][]" id="field_wogkw-0" value="Past" data-invmsg="Gaps in education is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_77-1"><label for="field_wogkw-1"><input type="checkbox" name="item_meta[77][]" id="field_wogkw-1" value="Present" data-invmsg="Gaps in education is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_683_container" class="frm_form_field form-field frm_top_container frm12 frm_first vertical_radio"> <div id="field_sxh8h_label" class="frm_primary_label">Domestic Violence <span class="frm_required" aria-hidden="true"></span> </div> <div class="frm_opt_container" aria-labelledby="field_sxh8h_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_683-0"><label for="field_sxh8h-0"><input type="checkbox" name="item_meta[683][]" id="field_sxh8h-0" value="Past" data-invmsg="Domestic Violence is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_683-1"><label for="field_sxh8h-1"><input type="checkbox" name="item_meta[683][]" id="field_sxh8h-1" value="Present" data-invmsg="Domestic Violence is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_78_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_wd2wo_label" class="frm_primary_label">Criminal history <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_wd2wo_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_78-0"><label for="field_wd2wo-0"><input type="checkbox" name="item_meta[78][]" id="field_wd2wo-0" value="Past" data-invmsg="Criminal history is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_78-1"><label for="field_wd2wo-1"><input type="checkbox" name="item_meta[78][]" id="field_wd2wo-1" value="Present" data-invmsg="Criminal history is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_79_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_rkdlz_label" class="frm_primary_label">Unstable housing/Homelessness <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_rkdlz_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_79-0"><label for="field_rkdlz-0"><input type="checkbox" name="item_meta[79][]" id="field_rkdlz-0" value="Past" data-invmsg="Unstable housing/Homelessness is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_79-1"><label for="field_rkdlz-1"><input type="checkbox" name="item_meta[79][]" id="field_rkdlz-1" value="Present" data-invmsg="Unstable housing/Homelessness is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_80_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_duvul_label" class="frm_primary_label">Loss or lack of employment <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_duvul_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_80-0"><label for="field_duvul-0"><input type="checkbox" name="item_meta[80][]" id="field_duvul-0" value="Past" data-invmsg="Loss or lack of employment is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_80-1"><label for="field_duvul-1"><input type="checkbox" name="item_meta[80][]" id="field_duvul-1" value="Present" data-invmsg="Loss or lack of employment is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_81_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_sy9ld_label" class="frm_primary_label">Loss or lack of transportation <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_sy9ld_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_81-0"><label for="field_sy9ld-0"><input type="checkbox" name="item_meta[81][]" id="field_sy9ld-0" value="Past" data-invmsg="Loss or lack of transportation is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_81-1"><label for="field_sy9ld-1"><input type="checkbox" name="item_meta[81][]" id="field_sy9ld-1" value="Present" data-invmsg="Loss or lack of transportation is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_82_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_dvo1d_label" class="frm_primary_label">Poverty <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_dvo1d_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_82-0"><label for="field_dvo1d-0"><input type="checkbox" name="item_meta[82][]" id="field_dvo1d-0" value="Past" data-invmsg="Poverty is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_82-1"><label for="field_dvo1d-1"><input type="checkbox" name="item_meta[82][]" id="field_dvo1d-1" value="Present" data-invmsg="Poverty is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_83_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_94ned_label" class="frm_primary_label">Drug or alcohol abuse <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_94ned_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_83-0"><label for="field_94ned-0"><input type="checkbox" name="item_meta[83][]" id="field_94ned-0" value="Past" data-invmsg="Drug or alcohol abuse is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_83-1"><label for="field_94ned-1"><input type="checkbox" name="item_meta[83][]" id="field_94ned-1" value="Present" data-invmsg="Drug or alcohol abuse is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_84_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_p36gg_label" class="frm_primary_label">Food insecurity <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_p36gg_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_84-0"><label for="field_p36gg-0"><input type="checkbox" name="item_meta[84][]" id="field_p36gg-0" value="Past" data-invmsg="Food insecurity is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_84-1"><label for="field_p36gg-1"><input type="checkbox" name="item_meta[84][]" id="field_p36gg-1" value="Present" data-invmsg="Food insecurity is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_553_container" class="frm_form_field form-field frm_top_container horizontal_radio"> <div id="field_r0l6m_label" class="frm_primary_label">Lack of child care <span class="frm_required"></span> </div> <div class="frm_opt_container" aria-labelledby="field_r0l6m_label" role="group"> <div class="frm_checkbox" id="frm_checkbox_553-0"><label for="field_r0l6m-0"><input type="checkbox" name="item_meta[553][]" id="field_r0l6m-0" value="Past" data-invmsg="Lack of child care is invalid" aria-invalid="false" /> Past</label></div> <div class="frm_checkbox" id="frm_checkbox_553-1"><label for="field_r0l6m-1"><input type="checkbox" name="item_meta[553][]" id="field_r0l6m-1" value="Present" data-invmsg="Lack of child care is invalid" aria-invalid="false" /> Present</label></div> </div> </div> <div id="frm_field_85_container" class="frm_form_field form-field frm_required_field frm_top_container vertical_radio"> <div id="field_aeiiv_label" class="frm_primary_label">If this client was involved in sex trafficking, to your best knowledge, does this client maintain ties to anyone they know/knew in "the life?" <span class="frm_required">*</span> </div> <div class="frm_opt_container" aria-labelledby="field_aeiiv_label" role="radiogroup" aria-required="true" tabindex="0"> <div class="frm_radio" id="frm_radio_85-0"><label for="field_aeiiv-0"> <input type="radio" name="item_meta[85]" id="field_aeiiv-0" value="Yes" data-reqmsg="This field cannot be blank." data-invmsg="If this client was involved in sex trafficking, to your best knowledge, does this client maintain ties to anyone they know/knew in "the life?" is invalid" aria-invalid="false" /> Yes</label></div> <div class="frm_radio" id="frm_radio_85-1"><label for="field_aeiiv-1"> <input type="radio" name="item_meta[85]" id="field_aeiiv-1" value="No" data-reqmsg="This field cannot be blank." data-invmsg="If this client was involved in sex trafficking, to your best knowledge, does this client maintain ties to anyone they know/knew in "the life?" is invalid" aria-invalid="false" /> No</label></div> <div class="frm_radio" id="frm_radio_85-2"><label for="field_aeiiv-2"> <input type="radio" name="item_meta[85]" id="field_aeiiv-2" value="N/A" data-reqmsg="This field cannot be blank." data-invmsg="If this client was involved in sex trafficking, to your best knowledge, does this client maintain ties to anyone they know/knew in "the life?" is invalid" aria-invalid="false" /> N/A</label></div> </div> </div> <div id="frm_field_86_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_kfnl2" id="field_kfnl2_label" class="frm_primary_label">How long have you been working with this client? <span class="frm_required">*</span> </label> <textarea name="item_meta[86]" id="field_kfnl2" rows="8" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="How long have you been working with this client? is invalid" aria-invalid="false" ></textarea> </div> <div id="frm_field_554_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_hgzj2" id="field_hgzj2_label" class="frm_primary_label">Are there any services your client is currently or in the past has utilized at your agency? <span class="frm_required">*</span> </label> <textarea name="item_meta[554]" id="field_hgzj2" rows="8" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Are there any services your client is currently or in the past has utilized at your agency? is invalid" aria-invalid="false" ></textarea> </div> <div id="frm_field_87_container" class="frm_form_field form-field frm_required_field frm_top_container vertical_radio"> <div id="field_21h7w_label" class="frm_primary_label">Please verify that your client meets the following criteria: <span class="frm_required">*</span> </div> <div class="frm_opt_container" aria-labelledby="field_21h7w_label" role="group" aria-required="true"> <div class="frm_checkbox" id="frm_checkbox_87-0"><label for="field_21h7w-0"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-0" value="Over the age of 18 at the start of programming" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Over the age of 18 at the start of programming</label></div> <div class="frm_checkbox" id="frm_checkbox_87-1"><label for="field_21h7w-1"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-1" value="Exhibits high risk factors for trafficking or exploitation, has been trafficked in the past, or has high barriers to employment" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Exhibits high risk factors for trafficking or exploitation, has been trafficked in the past, or has high barriers to employment</label></div> <div class="frm_checkbox" id="frm_checkbox_87-2"><label for="field_21h7w-2"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-2" value="Has a positive history with referring agency and demonstrates a commitment to personal growth" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has a positive history with referring agency and demonstrates a commitment to personal growth</label></div> <div class="frm_checkbox" id="frm_checkbox_87-3"><label for="field_21h7w-3"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-3" value="Has an ongoing relationship with a case manager at the referring agency and will continue with services throughout the duration of each phase" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has an ongoing relationship with a case manager at the referring agency and will continue with services throughout the duration of each phase</label></div> <div class="frm_checkbox" id="frm_checkbox_87-4"><label for="field_21h7w-4"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-4" value="The ability to commit to once a week virtual check-ins" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> The ability to commit to once a week virtual check-ins</label></div> <div class="frm_checkbox" id="frm_checkbox_87-5"><label for="field_21h7w-5"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-5" value="Has reliable internet access and a personal or shared computer (laptop/desktop/tablet) that can be used for the duration of the programming" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has reliable internet access and a personal or shared computer (laptop/desktop/tablet) that can be used for the duration of the programming</label></div> <div class="frm_checkbox" id="frm_checkbox_87-6"><label for="field_21h7w-6"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-6" value="Has access to a device that can record (video and photos) of assignments (ex. phone with camera, digital camera, tablet with webcam)" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has access to a device that can record (video and photos) of assignments (ex. phone with camera, digital camera, tablet with webcam)</label></div> <div class="frm_checkbox" id="frm_checkbox_87-7"><label for="field_21h7w-7"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-7" value="Has access to a kitchen with basic requirements: oven, stove, refrigerator, and sink" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has access to a kitchen with basic requirements: oven, stove, refrigerator, and sink</label></div> <div class="frm_checkbox" id="frm_checkbox_87-8"><label for="field_21h7w-8"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-8" value="Proficiency in spoken and written English communication" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Proficiency in spoken and written English communication</label></div> <div class="frm_checkbox" id="frm_checkbox_87-9"><label for="field_21h7w-9"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-9" value="Proficient in reading comprehension at a 3rd grade level or higher" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Proficient in reading comprehension at a 3rd grade level or higher</label></div> <div class="frm_checkbox" id="frm_checkbox_87-10"><label for="field_21h7w-10"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-10" value="Proficient in math at a 3rd grade level or higher" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Proficient in math at a 3rd grade level or higher</label></div> <div class="frm_checkbox" id="frm_checkbox_87-11"><label for="field_21h7w-11"><input type="checkbox" name="item_meta[87][]" id="field_21h7w-11" value="Has a desire to learn about basic culinary arts and food service/hospitality" data-reqmsg="This field cannot be blank." data-invmsg="Please verify that your client meets the following criteria: is invalid" aria-invalid="false" /> Has a desire to learn about basic culinary arts and food service/hospitality</label></div> </div> </div> <div id="frm_field_685_container" class="frm_form_field form-field frm_required_field frm_top_container"> <label for="field_u7njo" id="field_u7njo_label" class="frm_primary_label">What is your availability to set up a time to discuss your clients fit for our program? <span class="frm_required" aria-hidden="true">*</span> </label> <input type="text" id="field_u7njo" name="item_meta[685]" value="" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Text is invalid" aria-invalid="false" /> </div> <div id="frm_field_684_container" class="frm_form_field form-field frm_top_container"> <label for="field_kjl2g" id="field_kjl2g_label" class="frm_primary_label">Signature <span class="frm_required" aria-hidden="true"></span> </label> <div class="sigPad" id='sigPad684' style="max-width:400px;"> <div class="sig sigWrapper" style="height:150px;border-color:rgb(195,191,187);--bg-color:rgb(255,255,255);--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px"> <ul class="sigNav"> <li class="drawIt"><a href="#" class="frm-active-sig-type" title="Draw It" aria-label="Draw It"><i class="frm_icon_font frm_signature_icon" aria-hidden></i></a></li> <li class="typeIt"><a href="#" class="" title="Type It" aria-label="Type It"><i class="frm_icon_font frm_keyboard_icon" aria-hidden></i></a></li> </ul> <span class="frm-typed-drawline"></span> <div class="typed"> <input type="text" name="item_meta[684][typed]" class="name" id="field_kjl2g" autocomplete="off" value="" style="width:400px" maxlength="150" class="auto_width" aria-invalid="false" /> </div> <canvas class="pad" data-fieldid="684" data-fieldname="item_meta[684]" width="396" height="150"></canvas> <div class="clearButton"><a href="#clear">Clear</a></div> <input type="hidden" name="item_meta[684][output]" class="output" value="" /> </div> </div> </div> <input type="hidden" name="item_key" value="" /> <div class="frm_verify" aria-hidden="true"> <label for="frm_email_11"> If you are human, leave this field blank. </label> <input type="text" class="frm_verify" id="frm_email_11" name="frm_verify" value="" /> </div> <input name="frm_state" type="hidden" value="mQID1AOG9G1E/PIXhoTpUqgTHD5VwN92wUJABzAdzLk=" /><div class="frm_submit"> 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