HiddenEmail to Send Notification To* Name First Last Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 (WORD) 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: 98 MB.PhoneThis field is for validation purposes and should be left unchanged.
