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Member Assistance
Referral Page
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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
Referring Agents Email Address:
*
Email
Confirm Email
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
Couple
Family
I don't know
Name(s) of family members:
Phone Number for Member:
*
Email for Member:
*
Email
Confirm Email
Email for Member's spouse:
*
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?
*
Please select an option:
After the first and last sessions
After every session
Monthly
As needed
No updates needed
Other
'Updates how often' custom answer:
How would you like to be contacted?
Secure Email
Phone
Preferred Phone Number:
Check this box to automatically send an email to the person you are referring. The email will contain an online intake link and instructions on next steps.
Send email to member(s)
Comment
Submit
