{"id":37453,"date":"2023-06-29T13:14:59","date_gmt":"2023-06-29T18:14:59","guid":{"rendered":"https:\/\/texascasa.org\/?post_type=resources&#038;p=37453"},"modified":"2026-06-30T18:00:43","modified_gmt":"2026-06-30T23:00:43","slug":"solicitud-de-casa-de-cortesia","status":"publish","type":"resources","link":"https:\/\/texascasa.org\/es\/program-portal\/resources\/courtesy-casa-request\/","title":{"rendered":"Solicitud CASA de cortes\u00eda"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">This form is to be completed by the program requesting assistance. Please note, if a child is outside of the state of Texas, visits will be honored but may have delays due to travel scheduling. Additionally, please do not include confidential information. The form is meant to start the process. The Courtesy CASA program will follow up to securely obtain any additional confidential information needed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Courtesy CASAs can be requested for up to 50% of required in person visits and for safety concerns. Also, the initial in person visit must be conducted by the requesting program.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For more information on Courtesy CASA, check out the<strong> <a href=\"https:\/\/texascasa.org\/wp-content\/uploads\/2023\/06\/COURTESY-CASA-brochure-UPDATED-2023-1.pdf\">brochure<\/a><\/strong>. If you don\u2019t get a response within two business days call Courtesy CASA Manager Stevie Irby at 832-600-7665.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n    <script src=\"https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/3.6.0\/jquery.min.js\"><\/script>\n    \n\n<script language=\"javascript\">\n\njQuery(window).bind(\"pageshow\", function() {\n\n var historyTraversal = event.persisted || \n                         ( typeof window.performance != \"undefined\" && \n                              window.performance.navigation.type === 2 );\n  if ( historyTraversal ) {\n\tjQuery(\"form\").trigger(\"reset\");\n  }\n  jQuery(\"form\").trigger(\"reset\");\n});\n\n<\/script>\n<script>\nvar 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action='\/es\/wp-json\/wp\/v2\/resources\/37453' data-formid='16' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"195\" \/>\n\t\t\t\t\t\t<script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n\n\t\t\t\t\t<\/div><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Lfk1_sqAAAAAF-K_w8ELp6zTZCynXJelSOCeMQ0' data-tabindex='0'><input id=\"input_98db7cc4e827ffb86080e22f2d879e75\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_98db7cc4e827ffb86080e22f2d879e75\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_16_42\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s First Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_16_42'>\n                            \n                            <span id='input_16_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_16_42_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_16_42_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_16_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_43'>Child&#039;s Last Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_16_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_48\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_48'>Age of Child<\/label><div class='ginput_container ginput_container_number'><input name='input_48' id='input_16_48' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_16_1\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_1'>Case Number<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_16_1' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_3\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_3'>Program requesting courtesy service:<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_16_3' class='large gfield_select'     aria-invalid=\"false\" ><option value='Amarillo Area CASA' >Amarillo Area CASA<\/option><option value='Big Country CASA' >Big Country CASA<\/option><option value='Bluebonnet CASA' >Bluebonnet CASA<\/option><option value='Bluebonnet Children&#039;s Center' >Bluebonnet Children&#039;s Center<\/option><option value='Brush Country CASA' >Brush Country CASA<\/option><option value='CASA - Hope for Children, Inc.' >CASA &#8211; Hope for Children, Inc.<\/option><option value='CASA 69, Inc.' >CASA 69, Inc.<\/option><option value='CASA for Hunt County' >CASA for Hunt County<\/option><option value='CASA for KIDS' >CASA for KIDS<\/option><option value='CASA for Kids of East Texas' >CASA for Kids of East Texas<\/option><option value='CASA for Kids of South Central Texas' >CASA for Kids of South Central Texas<\/option><option value='CASA for the Cross Timbers Area, Inc' >CASA for the Cross Timbers Area, Inc<\/option><option value='CASA for the Highland Lakes Area' >CASA for the Highland Lakes Area<\/option><option value='CASA in the Heart of Texas' >CASA in the Heart of Texas<\/option><option value='CASA of Bastrop County' >CASA of Bastrop County<\/option><option value='CASA of Bee, Live Oak and McMullen Counties' >CASA of Bee, Live Oak and McMullen Counties<\/option><option value='CASA of Bell and Coryell Counties' >CASA of Bell and Coryell Counties<\/option><option value='CASA of Cameron &amp; Willacy Counties' >CASA of Cameron &amp; Willacy Counties<\/option><option value='CASA of Central Texas' >CASA of Central Texas<\/option><option value='CASA of Collin County' >CASA of Collin County<\/option><option value='CASA of Deep East Texas' >CASA of Deep East Texas<\/option><option value='CASA of Denton County, Inc.' >CASA of Denton County, Inc.<\/option><option value='CASA of El Paso' >CASA of El Paso<\/option><option value='CASA of Ellis County' >CASA of Ellis County<\/option><option value='CASA of Fannin County' >CASA of Fannin County<\/option><option value='CASA of Freestone &amp; Limestone Counties' >CASA of Freestone &amp; Limestone Counties<\/option><option value='CASA of Galveston County' >CASA of Galveston County<\/option><option value='CASA of Grayson County' >CASA of Grayson County<\/option><option value='CASA of Harrison County' >CASA of Harrison County<\/option><option value='CASA of Hidalgo County, Inc.' >CASA of Hidalgo County, Inc.<\/option><option value='CASA of Hill County' >CASA of Hill County<\/option><option value='CASA of Hood and Somervell Counties' >CASA of Hood and Somervell Counties<\/option><option value='CASA of Johnson County' >CASA of Johnson County<\/option><option value='CASA of Liberty\/Chambers Counties' >CASA of Liberty\/Chambers Counties<\/option><option value='CASA of McLennan County' >CASA of McLennan County<\/option><option value='CASA of Navarro County' >CASA of Navarro County<\/option><option value='CASA of North Texas' >CASA of North Texas<\/option><option value='CASA of Northeast Texas' >CASA of Northeast Texas<\/option><option value='CASA of South Texas' >CASA of South Texas<\/option><option value='CASA of Southeast Texas' >CASA of Southeast Texas<\/option><option value='CASA of Tarrant County, Inc.' >CASA of Tarrant County, Inc.<\/option><option value='CASA of the Coastal Bend' >CASA of the Coastal Bend<\/option><option value='CASA of the High Plains' >CASA of the High Plains<\/option><option value='CASA of the Permian Basin Area, Inc.' >CASA of the Permian Basin Area, Inc.<\/option><option value='CASA of the Pines, Inc.' >CASA of the Pines, Inc.<\/option><option value='CASA of the Rolling Plains, Inc.' >CASA of the Rolling Plains, Inc.<\/option><option value='CASA of the Sabine Neches Region' >CASA of the Sabine Neches Region<\/option><option value='CASA of the South Plains' >CASA of the South Plains<\/option><option value='CASA of Titus, Camp and Morris Counties' >CASA of Titus, Camp and Morris Counties<\/option><option value='CASA of Travis County' >CASA of Travis County<\/option><option value='CASA of Trinity Valley' >CASA of Trinity Valley<\/option><option value='CASA of Walker County' >CASA of Walker County<\/option><option value='CASA of West Texas' >CASA of West Texas<\/option><option value='CASA of Williamson County, Texas' >CASA of Williamson County, Texas<\/option><option value='CASA of Wise and Jack Counties' >CASA of Wise and Jack Counties<\/option><option value='Child Advocates CASA of Red River' >Child Advocates CASA of Red River<\/option><option value='Child Advocates of Fort Bend' >Child Advocates of Fort Bend<\/option><option value='Child Advocates of Montgomery County, Inc.' >Child Advocates of Montgomery County, Inc.<\/option><option value='Child Advocates San Antonio' >Child Advocates San Antonio<\/option><option value='Child Advocates, Inc.' >Child Advocates, Inc.<\/option><option value='Children&#039;s Advocacy Center of Greater West Texas' >Children&#039;s Advocacy Center of Greater West Texas<\/option><option value='Dallas CASA' >Dallas CASA<\/option><option value='East Texas CASA' >East Texas CASA<\/option><option value='Frontier CASA' >Frontier CASA<\/option><option value='Golden Crescent CASA, Inc.' >Golden Crescent CASA, Inc.<\/option><option value='Great Plains CASA for Kids' >Great Plains CASA for Kids<\/option><option value='Gulf Coast CASA' >Gulf Coast CASA<\/option><option value='Hill Country CASA' >Hill Country CASA<\/option><option value='Lake Country CASA' >Lake Country CASA<\/option><option value='Lone Star CASA, Inc.' >Lone Star CASA, Inc.<\/option><option value='North Star CASA' >North Star CASA<\/option><option value='Voices For Children Inc., CASA of Brazos Valley' >Voices For Children Inc., CASA of Brazos Valley<\/option><option value='Voz de Ninos' >Voz de Ninos<\/option><\/select><\/div><\/div><div id=\"field_16_5\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_5'>Program City<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_16_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_13'>County<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_16_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this an out of Texas request?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_6'>\n\t\t\t<div class='gchoice gchoice_16_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Yes'  id='choice_16_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_6_0' id='label_16_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_16_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_6_1' id='label_16_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_7\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_7'>Miles from requesting program to child(ren) placement<\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_16_7' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_16_15\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of staff making this request<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_16_15'>\n                            \n                            <span id='input_16_15_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.3' id='input_16_15_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_16_15_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_16_15_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.6' id='input_16_15_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_16_15_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_16_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_9'>Your Title (role of staff making the request)<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_16_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_10\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_10'>Your Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_16_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_11\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_11'>Your Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_16_11' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_16_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is a CASA Volunteer assigned to the case?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_12'>\n\t\t\t<div class='gchoice gchoice_16_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_16_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_12_0' id='label_16_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_16_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_12_1' id='label_16_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_16_14\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Volunteer&#039;s Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_16_14'>\n                            \n                            <span id='input_16_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_16_14_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_16_14_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_16_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_16_14_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_16_14_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_16_16\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_16'>Volunteer&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_16_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_17\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_17'>Volunteer&#039;s Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_16_17' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_16_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_20'>Number of children for the visit request<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_16_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_40'>Type of current placement<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_16_40' class='large gfield_select'     aria-invalid=\"false\" ><option value='Parental Home' >Parental Home<\/option><option value='Unrelated Foster Home' >Unrelated Foster Home<\/option><option value='Relative Foster Home' >Relative Foster Home<\/option><option value='Kinship Care' >Kinship Care<\/option><option value='Adoptive Placement' >Adoptive Placement<\/option><option value='Residential Treatment Center' >Residential Treatment Center<\/option><option value='Emergency Shelter' >Emergency Shelter<\/option><option value='Juvenile Detention Center' >Juvenile Detention Center<\/option><option value='Hospital' >Hospital<\/option><option value='HCS Home' >HCS Home<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_16_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_45'>City and State of current placement<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_16_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_19'>Date of last non-virtual face to face with child(ren)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_16_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_16_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_19' class='gform_hidden' value='https:\/\/texascasa.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_16_21\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_21'>Date of last visit with child(ren) (virtual included)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_16_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_16_21_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_21' class='gform_hidden' value='https:\/\/texascasa.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_16_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your program utilize Collaborative Family Engagement?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_24'>\n\t\t\t<div class='gchoice gchoice_16_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_16_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_24_0' id='label_16_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_16_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_24_1' id='label_16_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_25'>Provide a brief description of the CASA volunteer\u2019s time, contact and interaction on the case:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_16_25' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_16_26\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_26'>Date of next court hearing<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_16_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_16_26_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_26' class='gform_hidden' value='https:\/\/texascasa.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_16_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_27'>Goal or objective of the visit you are requesting:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_16_27' class='textarea large'  aria-describedby=\"gfield_description_16_27\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_16_27'><i>IMPORTANT: Do not include any confidential of identifying information; only the objective of the visit.<\/i><\/div><\/div><div id=\"field_16_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_28'>Safety concerns the program or volunteer has regarding the child(ren) or placement:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_16_28' class='textarea large'  aria-describedby=\"gfield_description_16_28\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_16_28'><i>IMPORTANT: Do not include any confidential of identifying information.<\/i><\/div><\/div><fieldset id=\"field_16_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PRIORITIZATION MATRIX \u2013 Reasons for request (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_30'><div class='gchoice gchoice_16_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='*Child(ren) have not been seen by CASA in over 180 days'  id='choice_16_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_1' id='label_16_30_1' class='gform-field-label gform-field-label--type-inline'>*Child(ren) have not been seen by CASA in over 180 days<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='*Recent abuse concerns in placement'  id='choice_16_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_2' id='label_16_30_2' class='gform-field-label gform-field-label--type-inline'>*Recent abuse concerns in placement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='*Child(ren) had a recent psychiatric hospitalization'  id='choice_16_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_3' id='label_16_30_3' class='gform-field-label gform-field-label--type-inline'>*Child(ren) had a recent psychiatric hospitalization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='*Child(ren) had a recent major incident (substance use, had run away, pregnancy, etc.)'  id='choice_16_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_4' id='label_16_30_4' class='gform-field-label gform-field-label--type-inline'>*Child(ren) had a recent major incident (substance use, had run away, pregnancy, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='*Child(ren) does not have an assigned CASA Volunteer'  id='choice_16_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_5' id='label_16_30_5' class='gform-field-label gform-field-label--type-inline'>*Child(ren) does not have an assigned CASA Volunteer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='*Child(ren) is nonverbal'  id='choice_16_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_6' id='label_16_30_6' class='gform-field-label gform-field-label--type-inline'>*Child(ren) is nonverbal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='*Placement in danger of disruption'  id='choice_16_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_7' id='label_16_30_7' class='gform-field-label gform-field-label--type-inline'>*Placement in danger of disruption<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Child(ren) moving to a new placement that requesting CASA has not visited'  id='choice_16_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_8' id='label_16_30_8' class='gform-field-label gform-field-label--type-inline'>Child(ren) moving to a new placement that requesting CASA has not visited<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Child(ren) need more in-person contact that requesting CASA can provide'  id='choice_16_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_9' id='label_16_30_9' class='gform-field-label gform-field-label--type-inline'>Child(ren) need more in-person contact that requesting CASA can provide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.11' type='checkbox'  value='Child(ren) placed in a RTC or lock-down facility'  id='choice_16_30_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_11' id='label_16_30_11' class='gform-field-label gform-field-label--type-inline'>Child(ren) placed in a RTC or lock-down facility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.12' type='checkbox'  value='Child(ren) having significant educational difficulties'  id='choice_16_30_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_12' id='label_16_30_12' class='gform-field-label gform-field-label--type-inline'>Child(ren) having significant educational difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.13' type='checkbox'  value='Child(ren) having significant emotional difficulties'  id='choice_16_30_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_13' id='label_16_30_13' class='gform-field-label gform-field-label--type-inline'>Child(ren) having significant emotional difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.14' type='checkbox'  value='Child(ren) with termination of parental rights'  id='choice_16_30_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_14' id='label_16_30_14' class='gform-field-label gform-field-label--type-inline'>Child(ren) with termination of parental rights<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.15' type='checkbox'  value='Child(ren) in both juvenile and CPS systems (cross-over case)'  id='choice_16_30_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_15' id='label_16_30_15' class='gform-field-label gform-field-label--type-inline'>Child(ren) in both juvenile and CPS systems (cross-over case)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.16' type='checkbox'  value='Child(ren) expressing desire for new placement'  id='choice_16_30_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_16' id='label_16_30_16' class='gform-field-label gform-field-label--type-inline'>Child(ren) expressing desire for new placement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.17' type='checkbox'  value='Judge ordered a new placement change without a homestudy'  id='choice_16_30_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_17' id='label_16_30_17' class='gform-field-label gform-field-label--type-inline'>Judge ordered a new placement change without a homestudy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.18' type='checkbox'  value='Child(ren) are 17 years or older'  id='choice_16_30_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_18' id='label_16_30_18' class='gform-field-label gform-field-label--type-inline'>Child(ren) are 17 years or older<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_31'>Reason for Placement<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_16_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_16_32\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_32'>Number of placements in last 12 months<\/label><div class='ginput_container ginput_container_number'><input name='input_32' id='input_16_32' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_16_33\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_33'>Length of time in this current placement<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_16_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does the child have any aggressive behaviors?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_35'>\n\t\t\t<div class='gchoice gchoice_16_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_16_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_35_0' id='label_16_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_16_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_35_1' id='label_16_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_16_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does the child have a disability?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_34'>\n\t\t\t<div class='gchoice gchoice_16_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_16_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_34_0' id='label_16_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_16_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_34_1' id='label_16_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_41'>If Other, please describe<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_16_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_16' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_16' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_16' id='gform_theme_16' value='orbital' \/>\n            <input type='hidden' 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