Referral Form

The first step in beginning services is completing a referral from.  This helps LIH collect more information about the individual(s) in need of services.  This in our initial step in getting started as the referral includes information such as age, diagnosis, reason for seeking services, funding source, as well as schedule availability.

Accessing the referral forms: It is important to know that you MUST download the file to your computer in order to complete the referral from in the “fillable form”.  If you do not wish to complete the referral as a fillable form, simply click on the “Non-Fillable Form” option, print from your home printer, hand write your responses, and return to LIH via fax/postal mail/emailed as an attachment.  

Referral Forms

Please return the referral form via email (admin@lihmt.com), via fax (414-377-3353), or by postal mail (860 Mill Street N, Suite 2, West Salem, WI 54669).  Once a referral is received, our team will be in contact to discuss the next steps in getting started with services.

Schedule Availability

After completing the referral, please complete this short availability form.  We look forward to blocking a time in our schedule just for YOU!