Advancing Public Health Since 1956
Kids' Health Connections - A Southeastern Michigan CHAP - Logo

Submit a Referral

Refer a Family to Kids’ Health Connections

If you would like to refer a family to KHC for services, you may download our referral form by clicking the “DOWNLOAD FORM” button below, and fax the form to (313) 659-3298.  Or, you may submit your referral online using our NEW secure “Online Referral Form” below!

Today's Date
Child's First Name
Child's Last Name
Child's Date of Birth (Ex. MM/DD/YYYY)
Child's Medicaid ID
Child's Health Plan
If you selected Private Insurance or other, please provide name:
Street 1
Street 2
City
State/Region
Postal Code
Parent name
Parent's Primary Telephone #
Parent's Secondary Telephone #
Name of Person or Physician Referring
Source of Referral
If your referral source is not listed, please provide name:
Practice or Agency Telephone
What need can KHC assist with?
I certify this child is cleared to participate in FitKids 360
Notes

Copyright © 2024 Kids' Health Connections (KHC)

Stay Connected

Kids’ Health Connections

3011 W. Grand Blvd., Ste 200
Detroit, MI 48202

Phone: (313) 863-2427 
Email: info@khcmi.org

Kids’ Health Connections is a program of the 501(c)(3) Southeastern Michigan Health Association.

New Site, Same Information!

Welcome to the newly launched Kids’ Health Connections website! You can find all the valuable content from our old site right here. Feel free to explore, and if you can’t locate something you need, our contact details are provided at the bottom of every page. Be sure to save our new web address for your next visit.