Row midpoint Shape Decorative svg added to bottom Submit a Self-Referral with Unite Us Unite Us is a closed loop referral system that has been integrated into the Sullivan County care network. You can use Unite Us software to speed up the delivery of referrals and reach outcomes faster. Fill out a self-referral to get started. Self Referral Name * Name First Name First Name Last Name Last Name Address * Phone * Email * Military Affiliation * CaregiverFamily MemberMilitary Member or VeteranMilitary SpousePrefer Not To DiscloseWidowedNone May we also text you at the phone number provided? * Yes No Is there another phone number to reach you? Are you completing this form on behalf of someone else? The client must sign the consent themselves. * Yes No What services are you seeking? * Benefits NavigationFood AssistanceHousing & ShelterIncome SupportIndividual & Family SupportUtilities Please describe your request for services. * Please Read The CONSENT FORM Please type your name in the box below to serve as your signature * To provide your consent for us to share the above information with United Sullivan partners as needed to be able to fulfill your request. Your information will ONLY be released to persons with a need to know and will be protected in accordance with HIPAA and 42 CFR Part 2 requirements. Submit If you are human, leave this field blank. Δ
