HiddenEmail to Send Notification To* Name First Last Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Other PhoneEmail Homeless?YesNoThird ChoiceClient Medical InformationDiagnoses: Current providers or support services:Recent inpatient or residential treatment (include date, location, and reason):Recent benefits or applications pending:Current assistance with benefits: City / State / County of Birth: Date of Birth Other informationReferral SourceReferring Person / Agency Agency Contact Email Agency Contact Phone Agency FaxRelease of InformationIf you are requesting services on behalf of someone else, please have them sign a release of information form to allow communication between you and ERI. Download a Consumer Consent to Release Information Form (pdf) If you have a completed form, please upload and attach to this form. Otherwise, you can email, fax, or send a consent form to ERI upon completion. Attach Release FormsMax. file size: 32 MB.EmailThis field is for validation purposes and should be left unchanged. Δ
