Member Assistance Referral Page

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 Christian Family Solutions take? At 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

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? *

Phone Number for Member: *

Email for Member: *

Email

Confirm Email

Is this referral for a minor? *

The Challenges

Please give a brief summary of the reason for the referral *

Has the referral been reported for domestic violence? *

Has the referral talked about ending his/her life? *

Are you aware of any current or past mental health treatment for this referral? *

Tell us how your organization 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 don't 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

Other:

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)

Blog

Information About the Referring Organization

Information About the Person You'd like to Refer

The Challenges

If the member has discussed ending his/her life please consider the safety of the member and whether immediate assistance through a local hospital or emergency facility is needed.

Tell us how your organization would like to assist

Tell us how you would like us to collaborate