Make a Referral

Do you know someone who could benefit from one of Healthy Living for ME’s health promotion workshops? Whether you are a friend, a relative, or a health professional, it’s easy to make a referral. When you refer someone to one of Healthy Living for ME's workshops, they will be contacted by a representative in their area within three business days. The representative will help them find a workshop that best fits their needs.

Please fill out the form completely. For more information about Healthy Living for ME workshops, please call us toll free at 1-800-620-6036.

*Required

Information of Person Being Referred

First Name

Last Name

Date of Birth

Phone

Insurance Provider

Insurance Group Number

Insurance Member ID

Primary Care Provider

City

State

County

Workshop the person is being referred for

Information of Person Offering the Referral

Full Name

Phone

Relationship to person being referred

Healthcare System

Additional Information

I have read the Privacy Policy and Terms of Use and I have obtained consent from the person I am referring to submit this referral on their behalf.

Workshop Search

Make a Referral

Information of Person Being Referred

Information of Person Offering the Referral