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 First Name
Child Last Name
Date of Birth
Email
Gender
Please select...
Male
Female
Other
Unknown at this time
Transgender
Non-binary/ Non-conforming
Prefer not to respond
Race
Please select...
First Nations/ Indigenous Peoples
Asian or Pacific Islander
Black or African American
White
Two or more races
Other
Unknown at this time
Ethnicity
Please select...
Hispanic or Latino
Not Hispanic or Latino
Unknown at this time
School District
Grade Level
Please select...
Preschool
4K
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
12+
Post Secondary
Other
Unknown at this time
Does the student have Section 504 Plan?
Please select...
Yes
No
Does the student have IEP?
Please select...
Yes
No
Insurance Coverage (please select all that apply):
BadgerCare/Medicaid
Private Insurance
Uninsured
Parent Information
Parent First Name
Parent Last Name
Parent Phone
Parent Email
Parent Street Address
Parent City
Parent Zip Code
Parent/Guardian County
Parent/Guardian State
Please select...
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Referrer's Information
Referrer's Role
Please select...
Parent
Educator
Human Services Social Worker
Medical/Mental Health Professional
Community Member
Other
Edit section title
Referrer's First Name
Referrer's Last Name
Referrer's Organization
Referrer's Phone
Referrer's Email
Relevant Background and Information
Family Challenges
Communication issues with provider or service system
Challenges developing/obtaining
a school plan that works for their child
Few natural supports in the community
On waitlist for services
Parent(s) or caregiver(s) needs a break / respite
Provider or service system has had difficulty engaging family
Referred to a community program but family has immediate needs that are not being met
Other
Other (Please Specify)
Child's Presenting Issues
Mental Health Concerns
Anxiety / agitation
Change in interests / change in engaging in activities
Change in temperament / typical mood
Depressed / lethargic / angry / sad
Hearing voices or delusional thinking
My child needs hospitalization or placement at a treatment facility
Need to find mental health programs for my child
Quickly-changing emotions
Self-harm / suicidal thoughts / suicide attempt
Unable to tolerate frustration
Challenging Behaviors
Challenging Behavior at home, school, or community
Difficulty in following directions/requests
Drug and/or alcohol use
Physical aggression
Property damage / destruction
Self-harm
Verbal Aggression
Relationship / Social Competence
Bullying (recipient)
Difficulty making friends / sustaining relationships
Negative self-view
Difficulty in Learning / School Issues
Exclusionary discipline (shortened school day, suspension, expulsion, etc.)
Inability to focus/attend
Inability to solve problems
Mistreatment or restraint / seclusion
School refusal
System or Court Involvement
Child welfare involvement / child protective services investigation
Law enforcement involvement / criminal activity
My child is returning from out-of-home placement
My child needs placement at a treatment facility
Other (Please specify)
Which of the following service is the child enrolled in? (Please select all that apply)
Please select...
Comprehensive Community Services (CCS)
Coordinated Services Team Initiative (CST)
Community Recovery Services(CRS)
Children’s Long-term Support Waiver (CLTS)
Intensive Autism Services under HealthCheck
Other (please enter program name)
Service Enrolment - Other
TO BE FILLED OUT BY HUMAN SERVICES AGENCY OR SCHOOL ONLY
Funding Program
Funding Hours Allotted Per Unit
Funding Units
Please select...
Week
Month
Year
End Date of Referral
Other Pertinent Information
By submitting this referral, I verify that the parent/guardian has authorized
Wisconsin Family Ties to contact them directly.
Contact Information