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

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.

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SEMHA is an Equal Opportunity Employer and welcomes all applicants. SEMHA is a Drug Free and Violence Free, Zero Tolerance Employer. SEMHA welcomes veterans and disabled veterans to apply. SEMHA employs able/disabled individuals.

Address

Fisher Building, Suite 200
3011 West Grand Boulevard
Detroit, Michigan
48202-3068 USA

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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.