Healthcare Support Application

Healthcare Support Form

Fill out the form below and our team will get back to you soon.

Section 1 — Applicant Information

Full Name

Email Address

Phone Number

Gender

Address

Are you a registered member of ECOH?

Section 2 — Case Details

Brief description of your healthcare need (in your own words)

Do you currently have health insurance?

How urgent is your need?

Section 3 — Agreement & Signature

I hereby request support from the Ethiopian Community Organization in Houston. I understand that ECOH is not a medical provider and cannot provide medical care. ECOH may assist through referrals, advocacy, and connecting me with culturally competent healthcare resources.

I have read and agree to the terms above. By submitting this form, I acknowledge that my electronic submission serves as my signature. *