Christian Family Solutions – Wisconsin Lutheran Child & Family Service, INC.

Name of person you are referring: *

First

Last

Date of birth for the person you are referring://

Gender of the person you are referring:

Is this referral for a minor? *

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: *

Current home address for child: *

Address Line 1

Address Line 2

City

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. *

ClinicalReferral Page