Referral Form

Who can refer children/families to Wisconsin Family Ties?


Literally anyone can make a referral. The most common referrers are parents themselves,
county human services employees, educators, and medical/mental health professionals.
Child Information

Child information is required to submit a referral. If you cannot provide the marked required fields* on this form, please get in touch with Wisconsin Family Ties directly. 

Parent Information

All parent / guardian information is required to submit a referral. If you are a non-parent referrer and do not have all the contact information below, please get in touch with Wisconsin Family Ties directly. 

Referrer's Information

If you are a parent, please select Parent under the Referrer's Role below. Otherwise, please enter your role and all contact details as a referrer.

IMPORTANT: Please enter the full name of your organization (e.g., Brown County Health and Human Services)
Family Issues
Please keep entry under 255 characters
Child's Presenting Issues





Please keep entry under 255 characters
Please keep entry under 255 characters
Services
TO BE FILLED OUT BY HUMAN SERVICES AGENCY OR SCHOOL ONLY

Send Referral Copy by Email
If you would like an email copy of this referral, please enter the email address below and one will be sent after the form is submitted.

By submitting this referral, I verify that the parent/guardian has authorized Wisconsin Family Ties to contact them directly.

NOTE: Referral form processing can take up to 60 seconds to be completed.  After clicking on the Submit button below, please do not close or refresh your browser screen until you see the "Form submitted!" message.

If receive an error message in the process of submitting this form, please do not re-attempt to submit the form.  Please contact Katy Herzfeld (kherzfeld@wifamilyties.org) for assistance.

Thank you!

Contact Information