Preferred Partner Enrollment
We are stronger together!
Partner Information
Today's Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Company Name
*
Company Logo
*
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Company Color Code. Ex. #fcc73d
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Website
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Name
*
First Name
Last Name
Primary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email
example@example.com
Partner Category
*
Please Select
Residential Treatment Provider
Intensive Outpatient Treatment Provider
Medical Detox Provider
Social Detox Provider
Peer Support Provider
Scholarship Organization
Community Partner
Giving Foundation
Grant Foundation
Drop In Center
Sober Living Facility
Other
Please select your company type based on your NCIS code
Describe the nature of services performed.
Clients you serve
Mental Health
Behavioral Health
Substance Use Disorder
Duel Diagnosis
Insurance Accepted
Colorado Medicaid (All RAEs)
Colorado Medicaid (Some RAEs)
Anthem/BCBS
Cigna/Evernorth
United Healthcare/Optum
Aetna
TriWest
Please describe your ideal client
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