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
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 practice or agency is not listed above, please provide name:
Practice or Agency Telephone
Why are you referring to KHC?
	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.