Community Partner Referral Form
Client Name
*
First Name
Last Name
Client Birth Date
*
-
Month
-
Day
Year
Month/Day/Year
Client Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does client need help with (check all that apply)
*
Health Coverage/Services
Food, Clothing & Other Resources
Utility/Energy Resources
Transportation to Medical Appointments
Referred By Name
*
First Name
Last Name
Referred by Email Address
*
example@example.com
Referred by Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referred by Organization Name (select from drop down)
Please Select
Boys and Girls Clubs of Greater Flint
Center for Hope
Clio Safety Net Store
Clio Senior Center
Community Unites/Family Futures
Communication Access Center
Consumers Energy
Crossover Outreach
FISH of Grand Blanc
Genesee County Free Medical Clinic
Henry Ford Medical Center-Downtown Flint
Henry Ford Medical Center-Burton
Journey Ministries
Luke 52 Project
Mayfair Bible Church
Ministry & Community Center
Michigan Works!
Motherly Intercession
Odyssey House
R.L. Jones Community Outreach Center
St. Mark Missionary Baptist Church
Other (please type name in next field)
Other Organization Name (if not listed above)
Additional Notes
Disclaimer Acknowledgement
*
The referring organization has received client consent to share their information with Genesee Health Plan. Client understands that Genesee Health Plan will contact them by phone, and client gives Genesee Health Plan permission to leave a message if client does not answer.
Submit
Should be Empty: