Question Title

* 1. Please provide the organization name.

Question Title

* 2. Please provide the organization address.

Question Title

* 3. Please provide the contact telephone number.

Question Title

* 4. Please provide the primary contact person's name.

Question Title

* 6. Type of Agency

Question Title

* 7. Select the fund/service you are interested in. Select all that apply.

Question Title

* 8. If In-Home service was selected above, please check all services your organization intends to provide.

Question Title

* 9. Type of Provider

Question Title

* 10. Does your agency have local office in the county you intend to serve?

Question Title

* 11. If applicable, does your agency have Board approved policies and procedures that support your proposed Care Coordination Program?

Question Title

* 12. Interested Agency understands that outreach, intake and assessment are the responsibility of the Agency that is awarded a contract for the services for which bid(s) are being submitted?

Question Title

* 13. Please provide a narrative explanation of intentions.

Question Title

* 14. Select the county or counties where services will be delivered. Select all that apply.

T