<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;">
        {{ form_errors(form) }}
        <br>&nbsp;<br> 
        </div>

            
        <h3>
        Referred From:
		<br><br>
        </h3>
        
        <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>
        <br>&nbsp;<br>
		<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/>
		<hr size="1" color="black" noshade/>
        <br>&nbsp;<br>
              
        <h3>
        Referrals:
        </h3>
         
		
	
		
<div style="float: left; padding:12px;">
        <div class="boxtitles">
		Dorcas Programs
		</div>

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

			<div id="dorcasprograms_benefitbank">
                        {{ form_widget(form.dorcasprograms_benefitbank) }}
                        {{ form_label(form.dorcasprograms_benefitbank) }}   
                    </div>
			<div id="dorcasprograms_budgetcounseling">
                        {{ form_widget(form.dorcasprograms_budgetcounseling) }}
                        {{ form_label(form.dorcasprograms_budgetcounseling) }}   
                    </div>
			<div id="dorcasprograms_childcare">
                        {{ form_widget(form.dorcasprograms_childcare) }}
                        {{ form_label(form.dorcasprograms_childcare) }}   
                    </div>	
			<div id="dorcasprograms_jobsforlifeatdorcas">
                        {{ form_widget(form.dorcasprograms_jobsforlifeatdorcas) }}   
                        {{ form_label(form.dorcasprograms_jobsforlifeatdorcas) }}
                    </div>	
			<div id="dorcasprograms_joblink">
                        {{ form_widget(form.dorcasprograms_joblink) }}   
                        {{ form_label(form.dorcasprograms_joblink) }}
                    </div>	
            <div id="dorcasprograms_margaretkeller">
                        {{ form_widget(form.dorcasprograms_margaretkeller) }}
                        {{ form_label(form.dorcasprograms_margaretkeller) }}   
                    </div>
			
			<div id="dorcasprograms_resourceoffice">
                        {{ form_widget(form.dorcasprograms_resourceoffice) }}
                        {{ form_label(form.dorcasprograms_resourceoffice) }}   
                    </div>	
			<div id="dorcasprograms_other">
                        {{ form_widget(form.dorcasprograms_other) }}   
                        {{ form_label(form.dorcasprograms_other) }}
                    </div>	
			
			
					
					
</div>
</div>					

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

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


			<div id="crisis_catholicparishoutreach">
                        {{ form_widget(form.crisis_catholicparishoutreach) }}   
                        {{ form_label(form.crisis_catholicparishoutreach) }}
                    </div>	
			<div id="crisis_resourcesforseniors">
                        {{ form_widget(form.crisis_resourcesforseniors) }}   
                        {{ form_label(form.crisis_resourcesforseniors) }}
                    </div>	
			<div id="crisis_salvationarmy">
                        {{ form_widget(form.crisis_salvationarmy) }}   
                        {{ form_label(form.crisis_salvationarmy) }}
                    </div>	
			<div id="crisis_trianglefamilyservices">
                        {{ form_widget(form.crisis_trianglefamilyservices) }}   
                        {{ form_label(form.crisis_trianglefamilyservices) }}
                    </div>	
			<div id="crisis_wakecountyhumanservices">
                        {{ form_widget(form.crisis_wakecountyhumanservices) }}   
                        {{ form_label(form.crisis_wakecountyhumanservices) }}
                    </div>	
			<div id="crisis_westernwake">
                        {{ form_widget(form.crisis_westernwake) }}   
                        {{ form_label(form.crisis_westernwake) }}
                    </div>	
			<div id="crisis_withlovefromjesus">
                        {{ form_widget(form.crisis_withlovefromjesus) }}   
                        {{ form_label(form.crisis_withlovefromjesus) }}
                    </div>	
			<div id="crisis_other">
                        {{ form_widget(form.crisis_other) }}   
                        {{ form_label(form.crisis_other) }}
                    </div>	
		
</div>
</div>					
					
             

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

<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_southwilmingtonstreetshelter">
                        {{ form_widget(form.housing_southwilmingtonstreetshelter) }}   
                        {{ form_label(form.housing_southwilmingtonstreetshelter) }}
                    </div>
            <div id="housing_wakeinterfaithhospitalitynetwork">
                        {{ form_widget(form.housing_wakeinterfaithhospitalitynetwork, { 'attr': {'style': 'float: left;'} }) }}
						<div style="width:280px;">						
							{{ form_label(form.housing_wakeinterfaithhospitalitynetwork) }}
						</div>                   
			</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:12px;">
        
		<div class="boxtitles">
		Employment
		</div>

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


			<div id="employment_jobsforlife">
                        {{ form_widget(form.employment_jobsforlife) }}   
                        {{ form_label(form.employment_jobsforlife) }}
                    </div>	
			<div id="employment_joblink">
                        {{ form_widget(form.employment_joblink) }}   
                        {{ form_label(form.employment_joblink) }}
                    </div>	
			<div id="employment_stepupministry">
                        {{ form_widget(form.employment_stepupministry) }}   
                        {{ form_label(form.employment_stepupministry) }}
                    </div>	
			<div id="employment_otheremploymentprogram">
                        {{ form_widget(form.employment_otheremploymentprogram) }}   
                        {{ form_label(form.employment_otheremploymentprogram) }}
                    </div>			
		
</div>
</div>		

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

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

			<div id="education_english">
                        {{ form_widget(form.education_english) }}   
                        {{ form_label(form.education_english) }}
					</div>
			 <div id="education_gedclasses">
                        {{ form_widget(form.education_gedclasses) }}   
                        {{ form_label(form.education_gedclasses) }}
                    </div>	
			<div id="education_waketechclasses">
                        {{ form_widget(form.education_waketechclasses) }}   
                        {{ form_label(form.education_waketechclasses) }}
                    </div>	
			<div id="education_parentingclasses">
                        {{ form_widget(form.education_parentingclasses) }}   
                        {{ form_label(form.education_parentingclasses) }}
                    </div>	
			<div id="education_othertraining">
                        {{ form_widget(form.education_othertraining) }}   
                        {{ form_label(form.education_othertraining) }}
                    </div>			

</div>
</div>

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

<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_figs">
                        {{ form_widget(form.medical_figs) }}   
                        {{ form_label(form.medical_figs) }}
            </div>
			<div id="medical_ncdentalbus">
                        {{ form_widget(form.medical_ncdentalbus) }}   
                        {{ form_label(form.medical_ncdentalbus) }}
            </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_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>

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

<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_wakementalhealth">
                        {{ form_widget(form.personalcounseling_wakementalhealth) }}   
                        {{ form_label(form.personalcounseling_wakementalhealth) }}
                    </div>		
			<div id="personalcounseling_othermentalhealth">
                        {{ form_widget(form.personalcounseling_othercounselingprogram) }}   
                        {{ form_label(form.personalcounseling_othercounselingprogram) }}
                    </div>			

</div>
</div>

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

<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="float: left; padding:12px; padding-right:24px;">
        
		<div class="boxtitles">
		Legal Services
		</div>

<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=" 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">
                        {{ form_widget(form.specialprograms_christmas) }}
                        {{ form_label(form.specialprograms_christmas) }}   
            </div>
            <div id="specialprograms_thanksgiving">
                        {{ form_widget(form.specialprograms_thanksgiving) }}
                        {{ form_label(form.specialprograms_thanksgiving) }}   
            </div>	
            <div id="specialprograms_emaillist">
                        {{ form_widget(form.specialprograms_emaillist) }}
                        {{ form_label(form.specialprograms_emaillist) }}   
            </div>
            <div id="specialprograms_other">
                        {{ form_widget(form.specialprograms_other) }}
                        {{ form_label(form.specialprograms_other) }}   
            </div>						
    </div>
</div>	


        {{ form_rest(form) }}

