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.

Question Title

* 1. Name:

Question Title

* 2. How can we contact you?

Phone:

Email:

Other:

Question Title

* 3. Address:

Question Title

* 4. Are you a Medi-Cal recipient?

Yes

I don't know

Other (please specify)

Question Title

* 5. Select all that apply to you.

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.

Question Title

* 6. Anything else you'd like to share about your health needs?

Question Title

* 7. How did you hear about CII's Enhanced Care Management program?

Social Media Ad

Google Ad

Other internet ads

Billboard

Referral from Another CII Program

Referral from Another Organization (please specify)