LHD Disparities Referral Form
Vibrant Health and Wellness Foundation in collaboration with the Prince George’s County Health Department, strives to reduce health disparities and building healthier communities by helping residents get the Health & Social Service resources they need to address those issues affecting their overall wellbeing.

Contact us!
Email: info@vhwf.org 
Phone: 301-966-7555
Fax: 301-966-7529 
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Referring Organization  (Organización Referida): *
First Name  (Primer nombre) : *
Last Name  (Apellido)  : *
Phone Number (Número de teléfono) : *
Email Address  (Correo electrónico) : *
Preferred Language  (Lenguaje preferido)  : *
Zip Code (Código postal): *
Telehub Referred to?   (Localidad de ayuda a la cual se le ha referido) : *
Type of Assistance Needed  (Tipo de asistencia necesaria) : *
Required
Additional Information you would like to provide               (Información adicional que le gustaría proporcionar) : *
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