Self-Management Workshop Referral Form

Self-Management Workshop Referral Form

Patient Information
First name
Middle initial
Last name
Phone number
Date of birth
Select the workshop(s) you are recommending for your patient.
Healthy Living with Diabetes
·  A six-week workshop for people with prediabetes or type 2 diabetes
Living Well with Chronic Conditions
·  A six-week workshop that empowers people withongoing health conditions
Stepping On
·  A seven-week workshop to teach fall prevention skills
For workshop dates and locations, to register or if you need more information about the self-management workshops please call 920-720-1655 or 800-769-3186 ext. 01655.
Submit this form to or fax 920-720-1975.

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