{% extends 'base.html.twig' %} {% block body %} {{ block('nav', 'internal/libs/nav.html.twig') }} <main class="main-content position-relative max-height-vh-100 h-100 border-radius-lg "> {{ block('topnav', 'internal/libs/top-nav.html.twig') }} <section> <div class="card card-plain"> <div class="card-header"> <h4 class="font-weight-bolder">Case Info</h4> <p class="mb-0"></p> </div> <div class="card-body"> <div class="container"> {{ form_errors(form) }} {{ form_start(form) }} <div class="row"> <div class='col'> <div class='input-group input-group-outline mb-3'> <label for='case_form_caseNumber' class='form-label'>Case #</label> <input type='text' name='{{ field_name(form.caseNumber) }}' id='case_form_caseNumber' class='form-control' required='required'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_dcsCaseId' class='form-label'>DCS Case ID</label> <input type='text' name='{{ field_name(form.dcsCaseId) }}' id='case_form_dcsCaseId' class='form-control' required='required'/> </div> <div class='input-group input-group-outline mb-3 is-filled'> <label for='case_form_admitDate' class='form-label'>Admit Date</label> <input type='date' name='{{ field_name(form.admitDate) }}' id='case_form_admitDate' class='form-control'/> </div> <div class='input-group input-group-outline mb-3 is-filled'> <label for='case_form_closeDate' class='form-label'>Close Date</label> <input type='date' name='{{ field_name(form.closeDate) }}' id='case_form_closeDate' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_caseEmail' class='form-label'>Case Email</label> <input type='text' name='{{ field_name(form.caseEmail) }}' id='case_form_caseEmail' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_referralType' class='form-label'>Referral Type</label> <input type='text' name='{{ field_name(form.referralType) }}' id='case_form_referralType' class='form-control'/> </div> <div class='input-group input-group-outline mb-3 is-filled'> <label for='case_form_level' class='form-label'>Level</label> <select name='{{ field_name(form.level) }}' id='case_form_level' class='form-control'> <option value=''></option> {% for l in enum('App\\Enums\\CaseLevel').cases() %} <option value='{{ l.value }}'>{{ l.name|replace({'_': ' '})|lower|capitalize }}</option> {% endfor %} </select> </div> <div class='input-group input-group-outline mb-3 is-filled'> <label for='case_form_referralSource' class='form-label'>Referral Source</label> <select name='{{ field_name(form.referralSource) }}' id='case_form_referralSource' class='form-control'> <option value=''></option> {% for src in sources %} <option value='{{ src.id }}'>{{ src.name}}</option> {% endfor %} </select> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_referralSources2' class='form-label'>2nd Referral Source</label> <select name='{{ field_name(form.referralSource2) }}' id='case_form_referralSources2' class='form-control'> <option value=''></option> {% for src in sources %} <option value='{{ src.id }}'>{{ src.name }}</option> {% endfor %} </select> </div> </div> <div class='col'> <div class='input-group input-group-outline mb-3'> <label for='case_form_firstName' class='form-label'>First Name</label> <input type='text' name='{{ field_name(form.firstName) }}' id='case_form_firstName' class='form-control' required='required'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_lastName' class='form-label'>Last Name</label> <input type='text' name='{{ field_name(form.lastName) }}' id='case_form_lastName' class='form-control' required='required'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_address' class='form-label'>Address</label> <input type='text' name='{{ field_name(form.address) }}' id='case_form_address' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_address2' class='form-label'>Address 2</label> <input type='text' name='{{ field_name(form.address2) }}' id='case_form_address2' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_city' class='form-label'>City</label> <input type='text' name='{{ field_name(form.city) }}' id='case_form_city' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_state' class='form-label'>State</label> <input type='text' name='{{ field_name(form.state) }}' id='case_form_state' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_zip' class='form-label'>Zip</label> <input type='text' name='{{ field_name(form.zip) }}' id='case_form_zip' class='form-control'/> </div> <div class='input-group input-group-outline mb-3 is-filled'> <label for='case_form_county' class='form-label'>County</label> <select name='{{ field_name(form.county) }}' id='case_form_county' class='form-control'> <option value=''></option> {% for c in enum('App\\Enums\\County').cases() %} <option value='{{ c.value }}'>{{ c.name }}</option> {% endfor %} </select> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_insurance' class='form-label'>Insurance</label> <input type='text' name='{{ field_name(form.insurance) }}' id='case_form_insurance' class='form-control'/> </div> <div class='input-group input-group-outline mb-3'> <label for='case_form_medicaid' class='form-label'>Medicaid</label> <input type='text' name='{{ field_name(form.medicaid) }}' id='case_form_medicaid' class='form-control'/> </div> </div> </div> <div class='row'> <div class="text-center"> <button type="submit" class="btn btn-lg bg-gradient-dark btn-lg w-100 mt-4 mb-0">Save Case</button> </div> </div> {{ form_end(form) }} </div> </div> </div> </section> </main> {% endblock %}