<?php

/* DorcasTabithaBundle:Referrals:referralslayout.html.twig */
class __TwigTemplate_afbab7926be69a83808bfc9542f9a117 extends Twig_Template
{
    public function __construct(Twig_Environment $env)
    {
        parent::__construct($env);

        $this->parent = false;

        $this->blocks = array(
        );
    }

    protected function doDisplay(array $context, array $blocks = array())
    {
        // line 1
        echo "<div id=\"navbar\" style=\"font-size:18px;\">   
    <ul>   
        <li><a href=\"javascript: submitform(9)\">Home</a></li>
        <li><a href=\"javascript: submitform(1)\">Client Information</a></li> 
        <li><a href=\"javascript: submitform(2)\">Finance</a></li>
        <li><a href=\"javascript: submitform(3)\">Notes</a></li>
        <li><a href=\"javascript: submitform(4)\">Assistance</a></li>
        <li><a href=\"javascript: submitform(5)\" style=\"background-color:#00b5cb; font-size:30px;\">Referrals</a></li> 
    </ul> 
</div> 
<br>&nbsp;
<input type=\"submit\" value=\"Save/Next\" style=\"color:#00b5cb; background-color:white;\">
<input type=\"button\" value=\"Cancel Changes\" onClick=\"window.location.reload()\" style=\"color:#00b5cb; background-color:white;\">


        <div style=\"color:maroon;\">
        ";
        // line 17
        echo $this->env->getExtension('form')->renderErrors($this->getContext($context, "form"));
        echo "
        <br>&nbsp;<br> 
        </div>

            
        <h3>
        Referred From:
\t\t<br><br>
        </h3>
        
        <div id=\"western_wake\">
            ";
        // line 28
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "western_wake"));
        echo "
            ";
        // line 29
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "western_wake"));
        echo "
            ";
        // line 30
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "western_wake"), array("attr" => array("size" => "3")));
        echo " 
        </div>
        <div id=\"western_wake_date\">
            ";
        // line 33
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "western_wake_date"));
        echo "
            ";
        // line 34
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "western_wake_date"));
        echo "
            ";
        // line 35
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "western_wake_date"), array("attr" => array("size" => "11", "class" => "datepicker", "onchange" => "wwdate(this)")));
        echo "
        </div>
         <div id=\"oxford_house\">
            ";
        // line 38
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "oxford_house"));
        echo "
            ";
        // line 39
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "oxford_house"));
        echo "
            ";
        // line 40
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "oxford_house"), array("attr" => array("size" => "3")));
        echo "
        </div>
        <div id=\"oxford_house_date\">
            ";
        // line 43
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "oxford_house_date"));
        echo "
            ";
        // line 44
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "oxford_house_date"));
        echo "
            ";
        // line 45
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "oxford_house_date"), array("attr" => array("size" => "11", "class" => "datepicker", "onchange" => "ohdate(this)")));
        echo "      </div>
        <br>&nbsp;<br>
\t\t<div id=\"church\">
            ";
        // line 48
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "church"));
        echo "
            ";
        // line 49
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "church"));
        echo "
            ";
        // line 50
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "church"));
        echo "
        </div>
        <div id=\"church_date\">
            ";
        // line 53
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "church_date"));
        echo "
            ";
        // line 54
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "church_date"));
        echo "
            ";
        // line 55
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "church_date"), array("attr" => array("size" => "11", "class" => "datepicker")));
        echo "
        </div>
\t\t<div id=\"other\">
            ";
        // line 58
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "other"));
        echo "
            ";
        // line 59
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "other"));
        echo "
            ";
        // line 60
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "other"), array("attr" => array("size" => "20")));
        echo "
        </div>
        <div id=\"other_date\">
            ";
        // line 63
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "other_date"));
        echo "
            ";
        // line 64
        echo $this->env->getExtension('form')->renderErrors($this->getAttribute($this->getContext($context, "form"), "other_date"));
        echo "
            ";
        // line 65
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "other_date"), array("attr" => array("size" => "11", "class" => "datepicker")));
        echo "
        </div>
\t\t<br/>
\t\t<hr size=\"1\" color=\"black\" noshade/>
        <br>&nbsp;<br>
              
        <h3>
        Referrals:
        </h3>
         
\t\t
\t
\t\t
<div style=\"float: left; padding:12px;\">
        <div class=\"boxtitles\">
\t\tDorcas Programs
\t\t</div>

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

\t\t\t<div id=\"dorcasprograms_benefitbank\">
                        ";
        // line 86
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_benefitbank"));
        echo "
                        ";
        // line 87
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_benefitbank"));
        echo "   
                    </div>
\t\t\t<div id=\"dorcasprograms_budgetcounseling\">
                        ";
        // line 90
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_budgetcounseling"));
        echo "
                        ";
        // line 91
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_budgetcounseling"));
        echo "   
                    </div>
\t\t\t<div id=\"dorcasprograms_childcare\">
                        ";
        // line 94
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_childcare"));
        echo "
                        ";
        // line 95
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_childcare"));
        echo "   
                    </div>\t
\t\t\t<div id=\"dorcasprograms_jobsforlifeatdorcas\">
                        ";
        // line 98
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_jobsforlifeatdorcas"));
        echo "   
                        ";
        // line 99
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_jobsforlifeatdorcas"));
        echo "
                    </div>\t
\t\t\t<div id=\"dorcasprograms_joblink\">
                        ";
        // line 102
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_joblink"));
        echo "   
                        ";
        // line 103
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_joblink"));
        echo "
                    </div>\t
            <div id=\"dorcasprograms_margaretkeller\">
                        ";
        // line 106
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_margaretkeller"));
        echo "
                        ";
        // line 107
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_margaretkeller"));
        echo "   
                    </div>
\t\t\t
\t\t\t<div id=\"dorcasprograms_resourceoffice\">
                        ";
        // line 111
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_resourceoffice"));
        echo "
                        ";
        // line 112
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_resourceoffice"));
        echo "   
                    </div>\t
\t\t\t<div id=\"dorcasprograms_other\">
                        ";
        // line 115
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_other"));
        echo "   
                        ";
        // line 116
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "dorcasprograms_other"));
        echo "
                    </div>\t
\t\t\t
\t\t\t
\t\t\t\t\t
\t\t\t\t\t
</div>
</div>\t\t\t\t\t

<div style=\"float: left; padding:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tCrisis Assistance Programs
\t\t</div>

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


\t\t\t<div id=\"crisis_catholicparishoutreach\">
                        ";
        // line 135
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_catholicparishoutreach"));
        echo "   
                        ";
        // line 136
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_catholicparishoutreach"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_resourcesforseniors\">
                        ";
        // line 139
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_resourcesforseniors"));
        echo "   
                        ";
        // line 140
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_resourcesforseniors"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_salvationarmy\">
                        ";
        // line 143
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_salvationarmy"));
        echo "   
                        ";
        // line 144
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_salvationarmy"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_trianglefamilyservices\">
                        ";
        // line 147
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_trianglefamilyservices"));
        echo "   
                        ";
        // line 148
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_trianglefamilyservices"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_wakecountyhumanservices\">
                        ";
        // line 151
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_wakecountyhumanservices"));
        echo "   
                        ";
        // line 152
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_wakecountyhumanservices"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_westernwake\">
                        ";
        // line 155
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_westernwake"));
        echo "   
                        ";
        // line 156
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_westernwake"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_withlovefromjesus\">
                        ";
        // line 159
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_withlovefromjesus"));
        echo "   
                        ";
        // line 160
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_withlovefromjesus"));
        echo "
                    </div>\t
\t\t\t<div id=\"crisis_other\">
                        ";
        // line 163
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "crisis_other"));
        echo "   
                        ";
        // line 164
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "crisis_other"));
        echo "
                    </div>\t
\t\t
</div>
</div>\t\t\t\t\t
\t\t\t\t\t
             

<div style=\"float: left; padding:12px; padding-right:12px;\">
        <div class=\"boxtitles\">
\t\tHousing Programs
\t\t</div>
\t\t

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

            <div id=\"housing_cornerstone\">
                        ";
        // line 181
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_cornerstone"));
        echo "
                        ";
        // line 182
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_cornerstone"));
        echo "   
                    </div>
            <div id=\"housing_raleighrescuemission\">
                        ";
        // line 185
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_raleighrescuemission"));
        echo "
                        ";
        // line 186
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_raleighrescuemission"));
        echo "          
                    </div>
            <div id=\"housing_salvationarmy\">
                        ";
        // line 189
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_salvationarmy"));
        echo "   
                        ";
        // line 190
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_salvationarmy"));
        echo "
                    </div>
            <div id=\"housing_southwilmingtonstreetshelter\">
                        ";
        // line 193
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_southwilmingtonstreetshelter"));
        echo "   
                        ";
        // line 194
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_southwilmingtonstreetshelter"));
        echo "
                    </div>
            <div id=\"housing_wakeinterfaithhospitalitynetwork\">
                        ";
        // line 197
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_wakeinterfaithhospitalitynetwork"), array("attr" => array("style" => "float: left;")));
        echo "
\t\t\t\t\t\t<div style=\"width:280px;\">\t\t\t\t\t\t
\t\t\t\t\t\t\t";
        // line 199
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_wakeinterfaithhospitalitynetwork"));
        echo "
\t\t\t\t\t\t</div>                   
\t\t\t</div>
\t\t\t<div id=\"housing_interact\">
                        ";
        // line 203
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_interact"));
        echo "   
                        ";
        // line 204
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_interact"));
        echo "
                    </div>
            <div id=\"housing_caryingplace\">
                        ";
        // line 207
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_caryingplace"));
        echo "   
                        ";
        // line 208
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_caryingplace"));
        echo "
                    </div>
            <div id=\"housing_other\">
                        ";
        // line 211
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "housing_other"));
        echo "   
                        ";
        // line 212
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "housing_other"));
        echo "
                    </div>        

</div> 
</div>  

<div style=\"float: left; padding:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tEmployment
\t\t</div>

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


\t\t\t<div id=\"employment_jobsforlife\">
                        ";
        // line 228
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "employment_jobsforlife"));
        echo "   
                        ";
        // line 229
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "employment_jobsforlife"));
        echo "
                    </div>\t
\t\t\t<div id=\"employment_joblink\">
                        ";
        // line 232
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "employment_joblink"));
        echo "   
                        ";
        // line 233
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "employment_joblink"));
        echo "
                    </div>\t
\t\t\t<div id=\"employment_stepupministry\">
                        ";
        // line 236
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "employment_stepupministry"));
        echo "   
                        ";
        // line 237
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "employment_stepupministry"));
        echo "
                    </div>\t
\t\t\t<div id=\"employment_otheremploymentprogram\">
                        ";
        // line 240
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "employment_otheremploymentprogram"));
        echo "   
                        ";
        // line 241
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "employment_otheremploymentprogram"));
        echo "
                    </div>\t\t\t
\t\t
</div>
</div>\t\t

<div style=\"float: left; padding:12px; padding-right:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tEducation
\t\t</div>

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

\t\t\t<div id=\"education_english\">
                        ";
        // line 256
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "education_english"));
        echo "   
                        ";
        // line 257
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "education_english"));
        echo "
\t\t\t\t\t</div>
\t\t\t <div id=\"education_gedclasses\">
                        ";
        // line 260
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "education_gedclasses"));
        echo "   
                        ";
        // line 261
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "education_gedclasses"));
        echo "
                    </div>\t
\t\t\t<div id=\"education_waketechclasses\">
                        ";
        // line 264
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "education_waketechclasses"));
        echo "   
                        ";
        // line 265
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "education_waketechclasses"));
        echo "
                    </div>\t
\t\t\t<div id=\"education_parentingclasses\">
                        ";
        // line 268
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "education_parentingclasses"));
        echo "   
                        ";
        // line 269
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "education_parentingclasses"));
        echo "
                    </div>\t
\t\t\t<div id=\"education_othertraining\">
                        ";
        // line 272
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "education_othertraining"));
        echo "   
                        ";
        // line 273
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "education_othertraining"));
        echo "
                    </div>\t\t\t

</div>
</div>

<div style=\"float: left; padding:12px; padding-right:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tHealth and Dental
\t\t</div>

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

\t\t\t<div id=\"medical_alliancemedicalministry\">
                        ";
        // line 288
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_alliancemedicalministry"));
        echo "   
                        ";
        // line 289
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_alliancemedicalministry"));
        echo "
            </div>
\t\t\t<div id=\"medical_figs\">
                        ";
        // line 292
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_figs"));
        echo "   
                        ";
        // line 293
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_figs"));
        echo "
            </div>
\t\t\t<div id=\"medical_ncdentalbus\">
                        ";
        // line 296
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_ncdentalbus"));
        echo "   
                        ";
        // line 297
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_ncdentalbus"));
        echo "
            </div>
\t\t\t<div id=\"medical_theopendoorclinic\">
                        ";
        // line 300
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_theopendoorclinic"));
        echo "   
                        ";
        // line 301
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_theopendoorclinic"));
        echo "
            </div>
\t\t\t<div id=\"medical_uncschoolofdentistry\">
                        ";
        // line 304
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_uncschoolofdentistry"));
        echo "   
                        ";
        // line 305
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_uncschoolofdentistry"));
        echo "
            </div>\t\t
\t\t\t<div id=\"medical_wakehealthservices\">
                        ";
        // line 308
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_wakehealthservices"));
        echo "   
                        ";
        // line 309
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_wakehealthservices"));
        echo "
            </div>\t
\t\t\t<div id=\"medical_othermedicalprogram\">
                        ";
        // line 312
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "medical_othermedicalprogram"));
        echo "   
                        ";
        // line 313
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "medical_othermedicalprogram"));
        echo "
            </div>\t
</div>
</div>

<div style=\"float: left; padding:12px; padding-right:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tMental Health
\t\t</div>

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

\t\t<div id=\"personalcounseling_centerforhopeandhealing\">
                        ";
        // line 327
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "personalcounseling_centerforhopeandhealing"));
        echo "   
                        ";
        // line 328
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "personalcounseling_centerforhopeandhealing"));
        echo "
                    </div>
\t\t\t<div id=\"personalcounseling_trianglefamilyservices\">
                        ";
        // line 331
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "personalcounseling_trianglefamilyservices"));
        echo "   
                        ";
        // line 332
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "personalcounseling_trianglefamilyservices"));
        echo "
                    </div>\t
\t\t\t<div id=\"personalcounseling_wakementalhealth\">
                        ";
        // line 335
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "personalcounseling_wakementalhealth"));
        echo "   
                        ";
        // line 336
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "personalcounseling_wakementalhealth"));
        echo "
                    </div>\t\t
\t\t\t<div id=\"personalcounseling_othermentalhealth\">
                        ";
        // line 339
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "personalcounseling_othercounselingprogram"));
        echo "   
                        ";
        // line 340
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "personalcounseling_othercounselingprogram"));
        echo "
                    </div>\t\t\t

</div>
</div>

<div style=\" float: left; padding:12px;\">
        
\t\t<div class=\"boxtitles\">
\t\tRecovery Programs
\t\t</div>

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

\t\t\t<div id=\"substanceabuseprograms_havenhouseinc\">
                        ";
        // line 355
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_havenhouseinc"));
        echo "   
                        ";
        // line 356
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_havenhouseinc"));
        echo "
                    </div>
\t\t\t<div id=\"substanceabuseprograms_oxfordhouse\">
                        ";
        // line 359
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_oxfordhouse"));
        echo "   
                        ";
        // line 360
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_oxfordhouse"));
        echo "
                    </div>\t
\t\t\t<div id=\"substanceabuseprograms_southlight\">
                        ";
        // line 363
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_southlight"));
        echo "   
                        ";
        // line 364
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_southlight"));
        echo "
                    </div>\t\t
\t\t\t<div id=\"substanceabuseprograms_thehealingplace\">
                        ";
        // line 367
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_thehealingplace"));
        echo "   
                        ";
        // line 368
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_thehealingplace"));
        echo "
                    </div>\t
\t\t\t<div id=\"substanceabuseprograms_trianglealanoclub\">
                        ";
        // line 371
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_trianglealanoclub"));
        echo "   
                        ";
        // line 372
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_trianglealanoclub"));
        echo "
                    </div>\t
\t\t\t<div id=\"substanceabuseprograms_othersubstanceabuseprogram\">
                        ";
        // line 375
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_othersubstanceabuseprogram"));
        echo "   
                        ";
        // line 376
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "substanceabuseprograms_othersubstanceabuseprogram"));
        echo "
                    </div>\t\t

</div>
</div>
<div style=\"float: left; padding:12px; padding-right:24px;\">
        
\t\t<div class=\"boxtitles\">
\t\tLegal Services
\t\t</div>

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

\t\t<div id=\"legalservices_legalaidofnorthcarolina\">
                        ";
        // line 390
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "legalservices_legalaidofnorthcarolina"));
        echo "   
                        ";
        // line 391
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "legalservices_legalaidofnorthcarolina"));
        echo "
                    </div>
\t\t\t<div id=\"legalservices_northcarolinalegalservicesinc\">
                        ";
        // line 394
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "legalservices_northcarolinalegalservicesinc"));
        echo "   
                        ";
        // line 395
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "legalservices_northcarolinalegalservicesinc"));
        echo "
                    </div>\t
\t\t\t<div id=\"legalservices_otherlegalservices\">
                        ";
        // line 398
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "legalservices_otherlegalservices"));
        echo "   
                        ";
        // line 399
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "legalservices_otherlegalservices"));
        echo "
                    </div>\t\t

</div>
</div>



<div style=\" padding:12px; float: left;\">
        
    <span class=\"boxtitles\">
        Special Programs
    </span>

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

            <div id=\"specialprograms_christmas\">
                        ";
        // line 416
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "specialprograms_christmas"));
        echo "
                        ";
        // line 417
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "specialprograms_christmas"));
        echo "   
            </div>
            <div id=\"specialprograms_thanksgiving\">
                        ";
        // line 420
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "specialprograms_thanksgiving"));
        echo "
                        ";
        // line 421
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "specialprograms_thanksgiving"));
        echo "   
            </div>\t
            <div id=\"specialprograms_emaillist\">
                        ";
        // line 424
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "specialprograms_emaillist"));
        echo "
                        ";
        // line 425
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "specialprograms_emaillist"));
        echo "   
            </div>
            <div id=\"specialprograms_other\">
                        ";
        // line 428
        echo $this->env->getExtension('form')->renderWidget($this->getAttribute($this->getContext($context, "form"), "specialprograms_other"));
        echo "
                        ";
        // line 429
        echo $this->env->getExtension('form')->renderLabel($this->getAttribute($this->getContext($context, "form"), "specialprograms_other"));
        echo "   
            </div>\t\t\t\t\t\t
    </div>
</div>\t


        ";
        // line 435
        echo $this->env->getExtension('form')->renderRest($this->getContext($context, "form"));
        echo "

";
    }

    public function getTemplateName()
    {
        return "DorcasTabithaBundle:Referrals:referralslayout.html.twig";
    }

    public function isTraitable()
    {
        return false;
    }

    public function getDebugInfo()
    {
        return array (  870 => 435,  861 => 429,  857 => 428,  851 => 425,  847 => 424,  841 => 421,  837 => 420,  831 => 417,  827 => 416,  807 => 399,  803 => 398,  797 => 395,  793 => 394,  787 => 391,  783 => 390,  766 => 376,  762 => 375,  756 => 372,  752 => 371,  746 => 368,  742 => 367,  736 => 364,  732 => 363,  726 => 360,  722 => 359,  716 => 356,  712 => 355,  694 => 340,  690 => 339,  684 => 336,  680 => 335,  674 => 332,  670 => 331,  664 => 328,  660 => 327,  643 => 313,  639 => 312,  633 => 309,  629 => 308,  623 => 305,  619 => 304,  613 => 301,  609 => 300,  603 => 297,  599 => 296,  593 => 293,  589 => 292,  583 => 289,  579 => 288,  561 => 273,  557 => 272,  551 => 269,  547 => 268,  541 => 265,  537 => 264,  531 => 261,  527 => 260,  521 => 257,  517 => 256,  499 => 241,  495 => 240,  489 => 237,  485 => 236,  479 => 233,  475 => 232,  469 => 229,  465 => 228,  446 => 212,  442 => 211,  436 => 208,  432 => 207,  426 => 204,  422 => 203,  415 => 199,  410 => 197,  404 => 194,  400 => 193,  394 => 190,  390 => 189,  384 => 186,  380 => 185,  374 => 182,  370 => 181,  350 => 164,  346 => 163,  340 => 160,  336 => 159,  330 => 156,  326 => 155,  320 => 152,  316 => 151,  310 => 148,  306 => 147,  300 => 144,  296 => 143,  290 => 140,  286 => 139,  280 => 136,  276 => 135,  254 => 116,  250 => 115,  244 => 112,  240 => 111,  233 => 107,  229 => 106,  223 => 103,  219 => 102,  213 => 99,  209 => 98,  203 => 95,  199 => 94,  193 => 91,  189 => 90,  183 => 87,  179 => 86,  155 => 65,  151 => 64,  147 => 63,  141 => 60,  137 => 59,  133 => 58,  127 => 55,  123 => 54,  119 => 53,  113 => 50,  109 => 49,  105 => 48,  99 => 45,  95 => 44,  91 => 43,  85 => 40,  81 => 39,  77 => 38,  71 => 35,  67 => 34,  63 => 33,  57 => 30,  49 => 28,  35 => 17,  17 => 1,  53 => 29,  50 => 12,  47 => 11,  41 => 7,  39 => 6,  33 => 5,  30 => 4,  27 => 3,);
    }
}
