Agency Referral Form 2026

Agency Information
Agency contact*

First NameLast Name
Agency name*
Agency phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Agency contact email*
example@example.com
Agency address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor has reviewed this request*

YesNo
Supervisor name*

First NameLast Name
Supervisor email*
example@example.com
Client Information
Client name*

First NameLast Name
Client gender*

MaleFemaleN/A
Client address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Date
Medical diagnosis*
Service requested description: (Please provide as much information as possible)*
Vendor (Who is to be paid)
Vendor name*
Vendor contact name*

First NameLast Name
Vendor address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vendor phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Item requested*
Amount/charge ($)*
Utility account number
Client account number
Client has given their permission for release of this information*

YesNo
All other sources of funding have been explored*

YesNo
Upload any necessary medical documents or copies of invoices

Cancelof
Convalescent Fund Policy:
    •    Location: Erie County residents only.
    •    Frequency: One time annually.
    •    Grant Amount: $300-$500 depending on the need.
    •    Restriction: No reimbursements of any kind.

Please review all above information carefully before submitting the application.
Should be Empty:

Agency Information

Client Information

Vendor (Who is to be paid)