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APPOINTMENT REQUEST

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Thank you for choosing the counseling services through Christian Family Solutions.

Emergency Help – If you feel like you may harm yourself or another person, please call 9-1-1 or go to your nearest emergency room. You can also speak with a live crisis counselor by calling 800.438.1772 and selecting option 1.

To request an appointment with a Christian counselor, please complete the information below or call 800.438.1772. After submitting the information below, a representative will contact you by the next business day to schedule an appointment. Completing this online request does not guarantee that an appointment can be scheduled. If you need to schedule an urgent appointment within the next business day, please contact us at the phone number above. To protect your privacy, all of the information you enter below is encrypted and stored securely.

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Patient's Name *

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Last

Address *

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City

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Zip Code

Preferred Phone Number *

Ok to leave a message at this number? *

Email *

Ok to contact you at this email address? *

Patients date of birth *

Patients Gender *

How do you plan to pay for the services you will receive? *

* An Employee Assistance Program (EAP) is a workplace benefit that provides short-term counseling services at no cost for the employees. Employee Assistance Programs usually require you to obtain authorization through your company’s EAP vendor. Contact your Human Resources department to see if your employer provides an EAP.

* Member Assistance Program (MAP) is a service provided to WELS/ELS organizations such as your congregation or school. Through MAP your organization provides counseling services for you at no cost. Most organizations participating in MAP require a referral. Contact your pastor/principal, or organizational leader to see if your organization is participating.

Name of your Employer:

Name of your Employee Assistance Program:

Phone number for your Employee Assistance Program:

Authorization Number: (Provided by your EAP)

Name of your organization:

Health Insurance Plan Name:

Are you covered by a Medicare or Medicaid Plan?

Subscriber's Name:

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Last

Subscriber's date of birth:

Subscriber's or Member ID Number:

Group Number:

Employer Name:

Verification/Customer Service Phone Number:

Have you previously seen a provider from Christian Family Solutions? *

Reason for Appointment:

Appointment Preference: *

Arizona

Phoenix (Emmaus Lutheran Church)
Gilbert (Heritage Lutheran Church)

Minnesota

Mankato
New Ulm (St Paul's Lutheran Church)
Rochester

Wisconsin

Appleton
Germantown
Hartford
Watertown
Muskego (St Paul's Community and Counseling Care Center)
Waukesha (Living Word Lutheran Church)

Other (Not Listed Above)

Day of the week preference: (Choose any that apply) *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Time of day preference: *

Morning
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Your Name: (If different from patient)

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By selecting this box, I verify that the information listed above is current and correct to the best of my knowledge. *

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Christian Family Solutions is an independent, non-profit agency that provides professional Christian counseling services and care for seniors. Our services are made more accessible to those in need through the generosity of our donors.

HEALING AND HELPING
PEOPLE IN NEED.

Contact Details

Corporate Address
W175 N11120 Stonewood Drive
Germantown, WI 53022

Corporate: 888-685-9522
Counseling: 800-438-1772
Counseling Fax: 262-345-5562

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