clinicalreferral.christianfamilysolutions.orgClinical Referral - Christian Family Solutions

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Please provide the referral information on the secure form below and a member of our intake team will promptly follow up with both you and the referred client. If you have questions, please call us at 800.438.1772 . Name of person you are referring: * First Last Date of birth for the person you are referring: MM 1 2 3 4 5 6 7 8 9 10 11 12 DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Gender of the person you are referring: Select One Male Female Is this referral for a minor? * Select One No Yes Parent or guardian Name: * First Last Parent or guardian phone number: * Parent or guardian email address: * Email Confirm Email Does the child have a caregiver different from above: * Select One Yes No Current home address for child: * Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Child’s School: Child’s grade: Has the child recieved mental health services in the past? If so, please describe: Client phone number: * Client email address: * Email Confirm Email Please provide a brief description of the reason for your referral. This will help our Intake Team when we call you to start the intake process. * Next Referring provider name: * First Last Referring provider email: * Email Confirm Email Referring provider phone number: * Referring provider’s organization: * Referring provider’s address: * Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Christian Family Solutions has my permission to reach out to this referred individual. * Yes Previous Next What is your relationship to the individual you are referring? (e.g., primary care physician, nurse practitioner, outpatient counselor, school counselor or other education professional) * Is there any other information you would like to share? To protect privacy, all of the information you have entered is encrypted and stored securely. After you submit this information, a Christian Family Solutions representative will contact you by the next business day. Email Submit Christian Family Solutions is an independent, non-profit agency that provides professional Christian counseling services and care for seniors. Our services are made more accessible to those in need through the generosity of our donors. HEALING AND HELPING PEOPLE IN NEED. Contact Details Corporate Address W175 N11120 Stonewood Drive Germantown, WI 53022 Corporate: 888-685-9522 Counseling: 800-438-1772 Counseling Fax: 262-345-5562 info@wlcfs.org Important Links COUNSELING CARE & SERVICES THE GARDENS OF HARTFORD CONTACT CAREERS GIVE Wisconsin Lutheran Child & Family Service, Inc. ©...