Make a Referral

Do you know someone who could benefit from a Texas Healthy at Home class? Whether you are a friend, relative or health professional, making a referral is easy. When you refer someone for a class, they will be contacted by someone who can answer any questions and help them register for the class.

Please fill out the form completely. For more information about Texas Healthy at Home classes, please email us at info@texashealthyathome.org.

*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

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

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Make a Referral

Information of Person Being Referred

Information of Person Offering the Referral