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Get in Touch with CII
Fill out the interest form below and a CII representative will be in touch to get you started.
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1.
Name:
(Required.)
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2.
How can we contact you?
(Required.)
Phone:
Email:
Other:
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3.
Zip Code:
(Required.)
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4.
Are you a Medi-Cal recipient?
(Required.)
Yes
No
I don't know
Other (please specify)
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5.
Select all that apply to you.
(Required.)
You are pregnant or have recently given birth.
You are seeking support for your child from birth to 5 years old.
You are a father seeking parenting support.
You are a parent with recent involvement with the Department of Child & Family Services.
You are currently or were previously in foster care.
You are struggling with mental health or a substance use disorder.
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 have been recently incarcerated or probation involved.
You have been exposed to violence in the home or in your community.
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6.
What age range is the individual you are seeking services for?
(Required.)
0-5 years old
6-18 years old
19-27 years old
27-64 years old
65+ years old
7.
Anything else you'd like to share about your health needs?
8.
How did you hear about CII?
Social Media
Search Engine (Google, Yahoo, etc)
Email
CII Staff at an Event - Outreach Table
Referral from Another CII Program
Referral from Another Organization (please specify)
