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! (* denotes a required field)

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 *
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 *
Reason for Referral *
	I certify this child is cleared to participate in FitKids 360
Notes

Stay Connected

Kids’ Health Connections

26555 Evergreen Rd., Suite 700, Southfield, MI 48076

Phone: (313) 863-2427
Email: khcinfo@semha.org

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

Advancing Public Health Since 1956

Submit a Referral

Refer a Family to Kids’ Health Connections

Stay Connected

Address

Submit a Referral

Refer a Family to Kids’ Health Connections

Stay Connected

New Site, Same Information!