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Enhanced Care Management Interest Form
Fill out the interest form below to see if you qualify for Enhanced Care Management, and a Children’s Institute Care Coordinator will be in touch to get you started.
*
1.
Name:
(Required.)
*
2.
How can we contact you?
(Required.)
Phone:
Email:
Other:
3.
Address:
*
4.
Are you a Medi-Cal recipient?
(Required.)
Yes
No
I don't know
Other (please specify)
*
5.
Select all that apply to you.
(Required.)
You are currently unhoused.
You have a complex health need (physical, behavioral or developmental)
You have had multiple emergency room visits or unplanned hospital admissions in the last six months.
You are struggling with mental health or a substance use disorder.
You have been incarcerated in the last 12 months.
You are or were previously in foster care.
You are pregnant or have recently given birth.
6.
Anything else you'd like to share about your health needs?
*
7.
How did you hear about CII's Enhanced Care Management program?
(Required.)
Google Ad
Email
Billboard
Referral from Another CII Program
TV
Referral from Another Organization (please specify)
