In Crisis?
Contact
Make A Payment
Connect With Your Provider
Request Appointment
888.685.9522
Member Assistance
Referral Page
Please enable JavaScript in your browser to complete this form.
1
2
3
4
Thank you for making a referral through your organization’s assistance program. This referral site is intended for an organization’s referral agent (pastor, principal, dean, human resources director). Please enter the information requested. If there is a concern about the individual’s safety, please contact your local hospital or speak with an on-call crisis counselor by calling
800.438.1772
, option 1.
What security measures does WLCFS-Christian Family Solutions take?
At WLCFS-Christian Family Solutions, the privacy and the security of your form data is of utmost importance to us. Please refer to our
privacy page
for a full list of measures that we take to ensure that your data is safe.
Information About the Referring Organization
Organization's Name:
*
Referring Agent's Name:
*
First
Last
Next
Information About the Person You'd like to Refer
Name of person you are referring:
*
First
Last
Is the referral for a couple or family?
*
No
Yes
I don't know
Name(s) of family members:
Phone Number for Member:
*
Email for Member:
*
Email
Confirm Email
Is this referral for a minor?
*
No
Yes
Age of the minor child:
Name of parent(s) or guardian:
Phone of parent or guardian:
Email for parent or guardian:
*
Email
Confirm Email
Previous
Next
The Challenges
Please give a brief summary of the reason for the referral
*
Has the referral been reported for domestic violence?
*
No
Yes
Has the referral talked about ending his/her life?
*
No
Yes
If the member has discussed ending his/her life please condiser the safety of the member and whether immediate assistance through a local hospital or emergency facility is needed.
Are you aware of any current or past mental health treatment for this referral?
*
No
Yes
Please describe:
Previous
Next
Tell us how your organizaiton would like to assist
If your organization does not have a pre-defined session limit, how many hours of service would you like to provide?
*
Tell us how you would like us to collaborate
How would the individual(s) prefer to meet with a counselor?
*
In person at a local Christian Family Solutions Clinic
Secure Video
Phone
I dont know
How often would you like to be updated on the progress of the individual you are referring?
How would you like to be contacted?
*
Secure Email
Phone
Phone
Submit
