  
<input type="submit" value="Next" style="color:#00b5cb; background-color:white;">
<br>&nbsp;<br>

        <div style="color:maroon;">
        {{ form_errors(form) }}
        </div>

        <hr />      
        <p>
        REFERRED FROM:
        </p>
        <hr />

        <div id="western_wake">
            {{ form_label(form.western_wake) }}
            {{ form_errors(form.western_wake) }}
            {{ form_widget(form.western_wake, { 'attr': {'size': '3'} }) }} 
        </div>
        <div id="western_wake_date">
            {{ form_label(form.western_wake_date) }}
            {{ form_errors(form.western_wake_date) }}
            {{ form_widget(form.western_wake_date, { 'attr': {'size': '11', 'class': 'datepicker', 'onchange': 'wwdate(this)'} }) }}
        </div>
         <div id="oxford_house">
            {{ form_label(form.oxford_house) }}
            {{ form_errors(form.oxford_house) }}
            {{ form_widget(form.oxford_house, { 'attr': {'size': '3'} }) }}
        </div>
        <div id="oxford_house_date">
            {{ form_label(form.oxford_house_date) }}
            {{ form_errors(form.oxford_house_date) }}
            {{ form_widget(form.oxford_house_date, { 'attr': {'size': '11', 'class': 'datepicker', 'onchange': 'ohdate(this)'} }) }}      </div>
        <div id="church">
            {{ form_label(form.church) }}
            {{ form_errors(form.church) }}
            {{ form_widget(form.church) }}
        </div>
        <div id="church_date">
            {{ form_label(form.church_date) }}
            {{ form_errors(form.church_date) }}
            {{ form_widget(form.church_date, { 'attr': {'size': '11', 'class': 'datepicker'} }) }}
        </div>
   <div id="other">
            {{ form_label(form.other) }}
            {{ form_errors(form.other) }}
            {{ form_widget(form.other, { 'attr': {'size': '20'} }) }}
        </div>
        <div id="other_date">
            {{ form_label(form.other_date) }}
            {{ form_errors(form.other_date) }}
            {{ form_widget(form.other_date, { 'attr': {'size': '11', 'class': 'datepicker'} }) }}
        </div>

        <br>&nbsp;<br>
        <hr />      
        <p>
        DORCAS PROGRAMS:
        </p>
        <hr />

        <div id="margaret_keller">
            {{ form_label(form.margaret_keller) }}
            {{ form_errors(form.margaret_keller) }}
            {{ form_widget(form.margaret_keller, { 'attr': {'size': '3'} }) }}
        </div>
        <div id="margaret_keller_date">
            {{ form_label(form.margaret_keller_date) }}
            {{ form_errors(form.margaret_keller_date) }}
            {{ form_widget(form.margaret_keller_date, { 'attr': {'size': '11', 'class': 'datepicker', 'onchange': 'mkdate(this)'} }) }}
        </div>
         <div id="childcare">
            {{ form_label(form.childcare) }}
            {{ form_errors(form.childcare) }}
            {{ form_widget(form.childcare, { 'attr': {'size': '3'} }) }}
        </div>
        <div id="childcare_date">
            {{ form_label(form.childcare_date) }}
            {{ form_errors(form.childcare_date) }}
            {{ form_widget(form.childcare_date, { 'attr': {'size': '11', 'class': 'datepicker', 'onchange': 'ccdate(this)'} }) }}
        </div>
        <div id="resource_office">
            {{ form_label(form.resource_office) }}
            {{ form_errors(form.resource_office) }}
            {{ form_widget(form.resource_office) }}
        </div>
        <div id="church_date">
            {{ form_label(form.resource_office_date) }}
            {{ form_errors(form.resource_office_date) }}
            {{ form_widget(form.resource_office_date, { 'attr': {'size': '11', 'class': 'datepicker'} }) }}
        </div>

        <br>&nbsp;<br>
        <hr />      
        <p>
        SHORT-TERM REFERRALS:
        </p>
        <hr />

<div style="float: left; padding:3px;">
        Housing

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

            <div id="housing_cornerstone">
                        {{ form_widget(form.housing_cornerstone) }}
                        {{ form_label(form.housing_cornerstone) }}   
                    </div>
            <div id="housing_raleighrescuemission">
                        {{ form_widget(form.housing_raleighrescuemission) }}
                        {{ form_label(form.housing_raleighrescuemission) }}          
                    </div>
            <div id="housing_salvationarmy">
                        {{ form_widget(form.housing_salvationarmy) }}   
                        {{ form_label(form.housing_salvationarmy) }}
                    </div>
            <div id="housing_panlutheranministries">
                        {{ form_widget(form.housing_panlutheranministries) }}   
                        {{ form_label(form.housing_panlutheranministries) }}
                    </div>
            <div id="housing_southwilmingtonstreetshelter">
                        {{ form_widget(form.housing_southwilmingtonstreetshelter) }}   
                        {{ form_label(form.housing_southwilmingtonstreetshelter) }}
                    </div>
            <div id="housing_thewomansshelter">
                        {{ form_widget(form.housing_thewomansshelter) }}   
                        {{ form_label(form.housing_thewomansshelter) }}
                    </div>
            <div id="housing_trianglefamilyservices">
                        {{ form_widget(form.housing_trianglefamilyservices) }}   
                        {{ form_label(form.housing_trianglefamilyservices) }}
                    </div>
            <div id="housing_wakecountyhumanservices">
                        {{ form_widget(form.housing_wakecountyhumanservices) }}   
                        {{ form_label(form.housing_wakecountyhumanservices) }}
                    </div>
            <div id="housing_wakeinterfaithhospitalitynetwork">
                        {{ form_widget(form.housing_wakeinterfaithhospitalitynetwork) }}   
                        {{ form_label(form.housing_wakeinterfaithhospitalitynetwork) }}
                    </div>
            <div id="housing_interact">
                        {{ form_widget(form.housing_interact) }}   
                        {{ form_label(form.housing_interact) }}
                    </div>
            <div id="housing_caryingplace">
                        {{ form_widget(form.housing_caryingplace) }}   
                        {{ form_label(form.housing_caryingplace) }}
                    </div>
            <div id="housing_other">
                        {{ form_widget(form.housing_other) }}   
                        {{ form_label(form.housing_other) }}
                    </div>        

</div> 
</div>  



<div style="float: left; padding:3px;">
        Financial
<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

            <div id="financial_wakecountyhumanservicesenergyprogram">
                        {{ form_widget(form.financial_wakecountyhumanservicesenergyprogram) }}   
                        {{ form_label(form.financial_wakecountyhumanservicesenergyprogram) }}
                    </div>	
			<div id="financial_trianglefamily">
                        {{ form_widget(form.financial_trianglefamily) }}   
                        {{ form_label(form.financial_trianglefamily) }}
                    </div>		
			<div id="financial_salvationarmy">
                        {{ form_widget(form.financial_salvationarmy) }}   
                        {{ form_label(form.financial_salvationarmy) }}
                    </div>	
			<div id="financial_northraleighministries">
                        {{ form_widget(form.financial_northraleighministries) }}   
                        {{ form_label(form.financial_northraleighministries) }}
                    </div>		
			<div id="financial_firstpresbyterianchurch">
                        {{ form_widget(form.financial_firstpresbyterianchurch) }}   
                        {{ form_label(form.financial_firstpresbyterianchurch) }}
                    </div>	
			<div id="financial_sacredheartchurch">
                        {{ form_widget(form.financial_sacredheartchurch) }}   
                        {{ form_label(form.financial_sacredheartchurch) }}
                    </div>	
			<div id="financial_otherfinancialassistanceprogram">
                        {{ form_widget(form.financial_otherfinancialassistanceprogram) }}   
                        {{ form_label(form.financial_otherfinancialassistanceprogram) }}
                    </div>	


</div>
</div>

<div style="float: left; padding:3px;">
        Food and Clothing
<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

<div id="foodandclothing_foodstampswakecountyhumanservices">
                        {{ form_widget(form.foodandclothing_foodstampswakecountyhumanservices) }}   
                        {{ form_label(form.foodandclothing_foodstampswakecountyhumanservices) }}
                    </div>	
			<div id="foodandclothing_urbanministriesfoodpantry">
                        {{ form_widget(form.foodandclothing_urbanministriesfoodpantry) }}   
                        {{ form_label(form.foodandclothing_urbanministriesfoodpantry) }}
                    </div>	
			<div id="foodandclothing_catholicparishoutreach">
                        {{ form_widget(form.foodandclothing_catholicparishoutreach) }}   
                        {{ form_label(form.foodandclothing_catholicparishoutreach) }}
                    </div>		
			<div id="foodandclothing_northraleighministries">
                        {{ form_widget(form.foodandclothing_northraleighministries) }}   
                        {{ form_label(form.foodandclothing_northraleighministries) }}
                    </div>		
			<div id="foodandclothing_salvationarmy">
                        {{ form_widget(form.foodandclothing_salvationarmy) }}   
                        {{ form_label(form.foodandclothing_salvationarmy) }}
                    </div>		
			<div id="foodandclothing_shepherdstable">
                        {{ form_widget(form.foodandclothing_shepherdstable) }}   
                        {{ form_label(form.foodandclothing_shepherdstable) }}
                    </div>	
			<div id="foodandclothing_withlovefromjesus">
                        {{ form_widget(form.foodandclothing_withlovefromjesus) }}   
                        {{ form_label(form.foodandclothing_withlovefromjesus) }}
                    </div>	
			<div id="foodandclothing_firstbaptistraleigh">
                        {{ form_widget(form.foodandclothing_firstbaptistraleigh) }}   
                        {{ form_label(form.foodandclothing_firstbaptistraleigh) }}
                    </div>		
			<div id="foodandclothing_otherfoodandclothingprogram">
                        {{ form_widget(form.foodandclothing_otherfoodandclothingprogram) }}   
                        {{ form_label(form.foodandclothing_otherfoodandclothingprogram) }}
                    </div>	
					
</div>
</div>	

<div style=" padding:3px;">
        Healthcare and Recovery
<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >	

		<div id="healthcareandrecovery_wakehealthservices">
                        {{ form_widget(form.healthcareandrecovery_wakehealthservices) }}   
                        {{ form_label(form.healthcareandrecovery_wakehealthservices) }}
                    </div>		
			<div id="healthcareandrecovery_opendoorclinic">
                        {{ form_widget(form.healthcareandrecovery_opendoorclinic) }}   
                        {{ form_label(form.healthcareandrecovery_opendoorclinic) }}
                    </div>	
			<div id="healthcareandrecovery_alliancemedicalministry">
                        {{ form_widget(form.healthcareandrecovery_alliancemedicalministry) }}   
                        {{ form_label(form.healthcareandrecovery_alliancemedicalministry) }}
                    </div>	
			<div id="healthcareandrecovery_thehealingplaceofwakecounty">
                        {{ form_widget(form.healthcareandrecovery_thehealingplaceofwakecounty) }}   
                        {{ form_label(form.healthcareandrecovery_thehealingplaceofwakecounty) }}
                    </div>		
			<div id="healthcareandrecovery_trianglealanoclub">
                        {{ form_widget(form.healthcareandrecovery_trianglealanoclub) }}   
                        {{ form_label(form.healthcareandrecovery_trianglealanoclub) }}
                    </div>	
			
			<div id="healthcareandrecovery_northcarolinabaptistdentalbus">
                        {{ form_widget(form.healthcareandrecovery_northcarolinabaptistdentalbus) }}   
                        {{ form_label(form.healthcareandrecovery_northcarolinabaptistdentalbus) }}
                    </div>	
			<div id="healthcareandrecovery_otherhealthcareandrecoveryprogram">
                        {{ form_widget(form.healthcareandrecovery_otherhealthcareandrecoveryprogram) }}   
                        {{ form_label(form.healthcareandrecovery_otherhealthcareandrecoveryprogram) }}
                    </div>			
					
					
</div>
</div>	


        <br>&nbsp;<br>
        <hr />      
        <p>
        LONG-TERM REFERRALS:
        </p>
        <hr />
		
<div style="float: left; padding:3px;">
        Comprehensive Programs

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >	

		<div id="comprehensiveprograms_cornerstone">
                        {{ form_widget(form.comprehensiveprograms_cornerstone) }}   
                        {{ form_label(form.comprehensiveprograms_cornerstone) }}
                    </div>	
			<div id="comprehensiveprograms_stepupministry">
                        {{ form_widget(form.comprehensiveprograms_stepupministry) }}   
                        {{ form_label(form.comprehensiveprograms_stepupministry) }}
                    </div>	
			<div id="comprehensiveprograms_thecaryingplace">
                        {{ form_widget(form.comprehensiveprograms_thecaryingplace) }}   
                        {{ form_label(form.comprehensiveprograms_thecaryingplace) }}
                    </div>		
			<div id="comprehensiveprograms_wakecountyhumanservices">
                        {{ form_widget(form.comprehensiveprograms_wakecountyhumanservices) }}   
                        {{ form_label(form.comprehensiveprograms_wakecountyhumanservices) }}
                    </div>	
			<div id="comprehensiveprograms_wakeinterfaithhospitalitynetwork">
                        {{ form_widget(form.comprehensiveprograms_wakeinterfaithhospitalitynetwork) }}   
                        {{ form_label(form.comprehensiveprograms_wakeinterfaithhospitalitynetwork) }}
                    </div>	
			<div id="comprehensiveprograms_othercomprehensiveprogram">
                        {{ form_widget(form.comprehensiveprograms_othercomprehensiveprogram) }}   
                        {{ form_label(form.comprehensiveprograms_othercomprehensiveprogram) }}
                    </div>				
					
</div>
</div>
		

<div style="float: left; padding:3px;">
        Employment

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >		


		<div id="employment_centerforhopeandhealing">
                        {{ form_widget(form.employment_centerforhopeandhealing) }}   
                        {{ form_label(form.employment_centerforhopeandhealing) }}
                    </div>	
			<div id="employment_dorcasministriesresourceoffice">
                        {{ form_widget(form.employment_dorcasministriesresourceoffice) }}   
                        {{ form_label(form.employment_dorcasministriesresourceoffice) }}
                    </div>	
			<div id="employment_joblink">
                        {{ form_widget(form.employment_joblink) }}   
                        {{ form_label(form.employment_joblink) }}
                    </div>	
			<div id="employment_jobsforlifeatdorcas">
                        {{ form_widget(form.employment_jobsforlifeatdorcas) }}   
                        {{ form_label(form.employment_jobsforlifeatdorcas) }}
                    </div>	
			<div id="employment_waketechcommunitycollegehrdclasses">
                        {{ form_widget(form.employment_waketechcommunitycollegehrdclasses) }}   
                        {{ form_label(form.employment_waketechcommunitycollegehrdclasses) }}
                    </div>	
			<div id="employment_otheremploymentprogram">
                        {{ form_widget(form.employment_otheremploymentprogram) }}   
                        {{ form_label(form.employment_otheremploymentprogram) }}
                    </div>			
		
		
		
		
</div>
</div>		

<div style="float: left; padding:3px;">
        Education

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >		

		<div id="education_margaretkellerscholarship">
                        {{ form_widget(form.education_margaretkellerscholarship) }}   
                        {{ form_label(form.education_margaretkellerscholarship) }}
                    </div>	
			<div id="education_waketechcommunitycollegeesl">
                        {{ form_widget(form.education_waketechcommunitycollegeesl) }}   
                        {{ form_label(form.education_waketechcommunitycollegeesl) }}
                    </div>	
			<div id="education_waketechcommunitycollegehrdclasses">
                        {{ form_widget(form.education_waketechcommunitycollegehrdclasses) }}   
                        {{ form_label(form.education_waketechcommunitycollegehrdclasses) }}
                    </div>	
			<div id="education_othertraining">
                        {{ form_widget(form.education_othertraining) }}   
                        {{ form_label(form.education_othertraining) }}
                    </div>			

</div>
</div>


<div style=" padding:3px;">
        Financial Counseling

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

		<div id="financialcounseling_budgetcounseling">
                        {{ form_widget(form.financialcounseling_budgetcounseling) }}   
                        {{ form_label(form.financialcounseling_budgetcounseling) }}
                    </div>
			<div id="financialcounseling_consumereducationcounseling">
                        {{ form_widget(form.financialcounseling_consumereducationcounseling) }}   
                        {{ form_label(form.financialcounseling_consumereducationcounseling) }}
                    </div>	
			<div id="financialcounseling_trianglefamilyservices">
                        {{ form_widget(form.financialcounseling_trianglefamilyservices) }}   
                        {{ form_label(form.financialcounseling_trianglefamilyservices) }}
                    </div>	
			<div id="financialcounseling_otherfinancialcounseling">
                        {{ form_widget(form.financialcounseling_otherfinancialcounseling) }}   
                        {{ form_label(form.financialcounseling_otherfinancialcounseling) }}
                    </div>		

</div>
</div>

<div style="float: left; padding:3px;">
        Legal Services

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

		<div id="legalservices_legalaidofnorthcarolina">
                        {{ form_widget(form.legalservices_legalaidofnorthcarolina) }}   
                        {{ form_label(form.legalservices_legalaidofnorthcarolina) }}
                    </div>
			<div id="legalservices_northcarolinalegalservicesinc">
                        {{ form_widget(form.legalservices_northcarolinalegalservicesinc) }}   
                        {{ form_label(form.legalservices_northcarolinalegalservicesinc) }}
                    </div>	
			<div id="legalservices_otherlegalservices">
                        {{ form_widget(form.legalservices_otherlegalservices) }}   
                        {{ form_label(form.legalservices_otherlegalservices) }}
                    </div>		

</div>
</div>


<div style="float: left; padding:3px;">
        Personal Counseling

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

		<div id="personalcounseling_centerforhopeandhealing">
                        {{ form_widget(form.personalcounseling_centerforhopeandhealing) }}   
                        {{ form_label(form.personalcounseling_centerforhopeandhealing) }}
                    </div>
			<div id="personalcounseling_trianglefamilyservices">
                        {{ form_widget(form.personalcounseling_trianglefamilyservices) }}   
                        {{ form_label(form.personalcounseling_trianglefamilyservices) }}
                    </div>	
			<div id="personalcounseling_westernwakehumanservicescenter">
                        {{ form_widget(form.personalcounseling_westernwakehumanservicescenter) }}   
                        {{ form_label(form.personalcounseling_westernwakehumanservicescenter) }}
                    </div>		
			<div id="personalcounseling_othercounselingprogram">
                        {{ form_widget(form.personalcounseling_othercounselingprogram) }}   
                        {{ form_label(form.personalcounseling_othercounselingprogram) }}
                    </div>			

</div>
</div>

<div style="float: left; padding:3px;">
        Substance Abuse Programs

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

		<div id="substanceabuseprograms_havenhouseinc">
                        {{ form_widget(form.substanceabuseprograms_havenhouseinc) }}   
                        {{ form_label(form.substanceabuseprograms_havenhouseinc) }}
                    </div>
			<div id="substanceabuseprograms_oxfordhouse">
                        {{ form_widget(form.substanceabuseprograms_oxfordhouse) }}   
                        {{ form_label(form.substanceabuseprograms_oxfordhouse) }}
                    </div>	
			<div id="substanceabuseprograms_southlight">
                        {{ form_widget(form.substanceabuseprograms_southlight) }}   
                        {{ form_label(form.substanceabuseprograms_southlight) }}
                    </div>		
			<div id="substanceabuseprograms_thehealingplace">
                        {{ form_widget(form.substanceabuseprograms_thehealingplace) }}   
                        {{ form_label(form.substanceabuseprograms_thehealingplace) }}
                    </div>	
			<div id="substanceabuseprograms_trianglealanoclub">
                        {{ form_widget(form.substanceabuseprograms_trianglealanoclub) }}   
                        {{ form_label(form.substanceabuseprograms_trianglealanoclub) }}
                    </div>	
			<div id="substanceabuseprograms_othersubstanceabuseprogram">
                        {{ form_widget(form.substanceabuseprograms_othersubstanceabuseprogram) }}   
                        {{ form_label(form.substanceabuseprograms_othersubstanceabuseprogram) }}
                    </div>		

</div>
</div>

<div style="padding:3px;">
        Medical

<div style="border:2px solid #ccc; width:300px; height: 100px; overflow-y: scroll;" >

		<div id="medical_alliancemedicalministry">
                        {{ form_widget(form.medical_alliancemedicalministry) }}   
                        {{ form_label(form.medical_alliancemedicalministry) }}
                    </div>
			<div id="medical_theopendoorclinic">
                        {{ form_widget(form.medical_theopendoorclinic) }}   
                        {{ form_label(form.medical_theopendoorclinic) }}
                    </div>
			<div id="medical_uncschoolofdentistry">
                        {{ form_widget(form.medical_uncschoolofdentistry) }}   
                        {{ form_label(form.medical_uncschoolofdentistry) }}
                    </div>		
			<div id="medical_wakecountyhumanservices">
                        {{ form_widget(form.medical_wakecountyhumanservices) }}   
                        {{ form_label(form.medical_wakecountyhumanservices) }}
                    </div>	
			<div id="medical_wakehealthservices">
                        {{ form_widget(form.medical_wakehealthservices) }}   
                        {{ form_label(form.medical_wakehealthservices) }}
                    </div>	
			<div id="medical_othermedicalprogram">
                        {{ form_widget(form.medical_othermedicalprogram) }}   
                        {{ form_label(form.medical_othermedicalprogram) }}
                    </div>	
</div>
</div>



        {{ form_rest(form) }}

