1. Please complete the following information:
Name:
Title:
Organization:
Telephone:
Address:
City:
State:
Zip:
Email:
2. Select the services your organization provides:
Family services
Substance abuse
Home health
Residential services
Day treatment
Outpatient mental health
Child Services
MR/DD
School based services
Employee assistance
Inpatient mental health
Foster care
Partial hospitalization
Crisis intervention
Other
If other, please specify:
3. Which departments from your organization will participate in the CareLogic software demonstration?
Executive
IT
Clinical
Intake
Billing
HR
Finance
Administrative
Implementation Team
4. Please rank in order of importance the following functionality requirements your organization would like to see during the demo.
Clinical Record
Select An Option
Priority
Important
Non-essential
Point of Entry
Select An Option
Priority
Important
Non-essential
Billing
Select An Option
Priority
Important
Non-essential
HR
Select An Option
Priority
Important
Non-essential
Clinical Treatment
Select An Option
Priority
Important
Non-essential
Scheduling
Select An Option
Priority
Important
Non-essential
Cash Application
Select An Option
Priority
Important
Non-essential
Caseload Management
Select An Option
Priority
Important
Non-essential
Front Desk
Select An Option
Priority
Important
Non-essential
A/R
Select An Option
Priority
Important
Non-essential
Reporting
Select An Option
Priority
Important
Non-essential
5. What is your annual operating budget?
Select An Option
$0-5M
$5-10M
$10-25M
$25-50M
$50-250M
$250M+
Other
If other, please specify:
6. How many full time employees does your organization have?
7. How many physical locations do you have?
8. What is your timeframe for selecting a new software package?
Select An Option
Within 90 days
90-180 days
180-360 days
No timeline presently
Other
If other, please specify:
9. Please list the key stakeholders for your group.
Executive:
Clinical:
Finance:
Administrative:
Information Technology:
10. Please select your preference for software delivery.
Select An Option
SaaS/ASP (Vendor hosted)
Internal
Undecided
11. Has a budget been allocated for this project?
Select An Option
Yes
No
12. Please list the software packages you are currently using for accounting, electronic record and other critical applications.
13. How did you hear about us?
14. Please describe any additional information that would be helpful for the Qualifacts staff to understand your needs and priorities.