ESRA PROGRAM SELF-REFERRAL FORM

Please complete the following form and press the "Submit" button at the bottom of the form. "Submit" will forward a copy of the form to The Effective Case Management (ECM) Group. A Nurse Consultant will contact you shortly to provide more information on the ESRA Program and the services available to help you recover from your illness or injury. If you would like to speak to a nurse consultant directly, please call 1-800-472-4904.
 

Ministry / Agency:
Date:
Employee Information
Employee Name (first/last):
Employee Number:
Job Title:
Date Absence Commenced or Will Commence:
Contact Information:
Employee’s Address:
Home Phone Number:
Work Phone Number:
  This form will be forwarded to the ECM Group.
Erases all entered information. Nothing is forwarded.