Community Engagement Consulting Services Application

Community Engagement Consulting Services Application
Company Name
Company Representative Name

First NameLast Name
Company Representative Role/Job Title
Company Representative Phone Number
Please enter a valid phone number.
Company Representative Email Address
example@example.com
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone Number
Please enter a valid phone number.
Company Website
Social Media Platforms
What year was the company established?
What type of business is the company you are representing?

For-profitNonprofit (501(c)(3) or similar)Not Applicable
How many employees, contractors, and other staff does the company currently have?
How many clients, on average does the company service per month?
Which of the following categories does the company provide services in? (Check all that apply.)

Mental/Behavioral HealthFinanceHousingVeteransLegalRe-entryChild CareEmploymentParentingEducationHealthcareTransportationFoodClothingOther
Please provide a detailed description of the services your company offers. If you selected 'Other,' please specify and elaborate on any additional services not listed above.
Does the company receive Medicaid reimbursement for any of the services it provides?

YesNo
Which forms of payment does the company accept? (Check all that apply.)

MedicaidMedicareCommercial InsurancesPrivate PaySliding ScaleFree services are offeredGrant-fundedOther

Service Legend

ACT	Assertive Community Treatment
PHP	Partial Hospitalization
IOP	Intensive Outpatient
23-Hr	23-Hour
MCR	Mobile Crisis Response
CS	Community Stabilization
MHSS	Mental Health Skill-Building Services
IIH	Intensive In-Home
PSR	Psychosocial Rehabilitation
TDT	Therapeutic Day-Treatment
OPT	Outpatient Psychotherapy
PRS	Peer Recovery Support
Res	Residential Treatment
FFT	Functional Family Therapy
MST	Multisystemic Therapy
ABA	Applied Behavior Analysis
Med Mgmt	Medication Management
Psych Evals	Psychological Evaluation
Home Health	Home Healthcare
Vision	Vision
Dental	Dental
PCP	Primary Care Physician
Hospice	Hospice
Speech	Speech
OB/GYN	Obstetrics/Gynecology
OTP	Opiod Treatment Programs
Hearing	Hearing

*MEDICAID INSURANCES ONLY* Please indicate which services the company offers and which Managed Care Organizations (MCOs) the company is credentialed with through MEDICAID for each service it offers. (Check all that apply.)

	Sentara	Aetna	Anthem	UHC	MCC	VA Premier	Cardinal Care	Other4	Other5
ACT
PHP
IOP
23-Hr
MCR
CS
MHSS
IIH
PSR
TDT
OPT
PRS
Res
FFT
MST
ABA
MedMgmt
PsychEvals
Home Health
Vision
Dental
PCP
Hospice
Speech
OBGYN
OTP
Hearing
Other1
Other2
Other3

If you selected "Other", please specify which services and/or which Managed Care Organization was not listed above.

*COMMERCIAL INSURANCES ONLY* Please indicate which services the company offers and Managed Care Organizations (MCOs) the company is credentialed with through COMMERCIAL insurances for each service it offers. (Check all that apply.)

	Sentara	Aetna	Anthem	UHC	MCC	VA Prem	Cardinal Care	Other9	Other10
OPT
Res
ABA
MedMgmt
PsychEvals
Home Health
Vision
Dental
PCP
Hospice
Speech
OBGYN
Other6
Other7
Other8

If you selected "Other", please specify which services and/or which Managed Care Organization was not listed above.

*MEDICARE INSURANCES ONLY* Please indicate which services the company offers and Managed Care Organizations (MCOs) the company is credentialed with through COMMERCIAL insurances for each service it offers. (Check all that apply.)

	UHC	Humana	Aetna	Anthem BCBS	Cigna	Sentara	WellCare	Other14	Other15
OPT
Res
ABA
MedMgmt
PsychEvals
Home Health
Vision
Dental
PCP
Hospice
Speech
OBGYN
Other6
Other7
Other8

If you selected "Other", please specify which services and/or which Managed Care Organization was not listed above.

*TRICARE INSURANCE ONLY* Please indicate which services the company offers and Managed Care Organizations (MCOs) the company is credentialed with through TRICARE insurance for each service it offers. (Check all that apply.)

	Humana Military	Other19	Other20
OPT
Res
ABA
MedMgmt
PsychEvals
Home Health
Vision
Dental
PCP
Hospice
Speech
OBGYN
Other16
Other17
Other18

If you selected "Other", please specify which services and/or which Managed Care Organization was not listed above.
Were you able to list all of the services the company provides?

YesNo
If you selected ‘NO,’ please list any services the company provides that have not been previously listed.”
Were you able to list all of the Managed Care Organizations the company is credentialed with?

YesNo
If you selected ‘NO,’ please list any Managed Care Organizations with which the company is credentialed that have not been previously listed.
Please specify which areas of the company need the most support?

Community EngagementVisibilityInternal Systems & ProcessesStaffingStaff RetentionStaff TrainingClient RetentionQuality of Service
Please elaborate on the weaknesses that have been identified in the selected area(s).
What differentiates the company from other service providers in the industry? What unique qualities or strengths make it stand out from competitors?
What is the company’s current annual budget for investing in A Major Connection's Community Engagement Consulting services?
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