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

Gender

Race

Ethnicity

School District

Grade Level

Does the student have Section 504 Plan?

Does the student have IEP?

Insurance Coverage (please select all that apply):

BadgerCare/MedicaidPrivate InsuranceUninsured

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

Referrer's Information

Referrer's Role

Referrer's First Name

Referrer's Last Name

Referrer's Organization

Referrer's Phone

Referrer's Email

Family Issues

Family Challenges

Communication issues with provider or service systemChallenges developing/obtaining a school plan that works for their childFew natural supports in the communityOn waitlist for servicesParent(s) or caregiver(s) needs a break / respiteProvider or service system has had difficulty engaging familyReferred to a community program but family has immediate needs that are not being metOther

Other (Please Specify)

Please keep entry under 255 characters

Other Pertinent Information

Services

Which of the following services is the child enrolled in? (Please select all that apply)

Service Enrollment - Other

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. Thank you!