You can Refer Yourself or Family for Help

You know yourself and family better than anyone else does. You don't have to wait for a doctor, nurse or social worker to refer you to our Center.

You may:

Call us at (205) 939-6123 (or)
Complete Form Below to Submit Online (or)
Print Referral Form and mail to Children's Harbor Family Center

Adobe Acrobat required to Print Referral Form
Need a Free Copy
Download Adobe Acrobat Reader

Children's Harbor Family Center will use the information you provide below for contacting you to see how we may provide a service to you and your family. Confidentiality is strictly maintained.

First Name
Last Name
Address
City
State
Zip
Are you or your child presently in the hospital? Yes No
If yes, room number
If yes, phone number
Primary Physician
Home Phone
Work Phone
Email Address
Reason for wanting service:
How did you learn about Children's Harbor? :

Children's Harbor, Inc.
1 Our Children's Highway
Children's Harbor, AL 35010-8620
Phone: (334) 857-2133
Fax: (334) 857-2516

Children's Harbor Family Center
at Children's Hospital
1600 6th Avenue South, Suite 200
Birmingham, AL 35233-1711
Phone: (205) 939-6123
Fax: (205) 939-6313