Make a Referral

Do you know someone who could benefit from one of NDC3’s health promotion classes? 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 NDC3's classes, they will be contacted by a representative within three business days. The representative will help them find a class that best fits their needs.

Please fill out the form completely. For more information about NDC3 classes, please contact us.

To find a class for yourself, please use the Find a Class at the top of the page to search and register for nearby classes, or use the form below to refer yourself to a class and be contacted by a program representative.

*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

Referrer Information

Full Name

Phone

Relationship to person being referred

Healthcare System

Additional Information

I have read the NDC3 Privacy Policy and Terms of Use and I have obtained consent from the person I am referring to submit this referral on their behalf.