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

NOTE: If you are referring through our Member Assistance Program (MAP), please refer through the MAP form. All other referents, please use the form below. Thank you for your referral.

Christian Family Solutions works collaboratively with referents so the client experiences consistent, coordinated care. 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

Is this referral for a minor? *

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. *

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

State

Zip Code

Christian Family Solutions has my permission to reach out to this referred individual. *

Yes

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.

ClinicalReferral Page

NOTE: If you are referring through our Member Assistance Program (MAP), please refer through the MAP form. All other referents, please use the form below. Thank you for your referral.

Clinical
Referral Page