CIE For-Profit Participation Survey

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CIE For-Profit Participation Survey - CIE San Diego

For-Profit CIE Participation Survey

All for-profit agencies must complete the following survey to begin the CIE Network Partner inclusion application process.

Business Name

Why do you want to become a CIE Partner?

Are you able to attend the next CIE Partner Network Meeting and answer potential questions from the CIE Partner Network about your services? CIE partner meeting occur the 4th Thursday of every month from 9:00 am-10:30 am.

Yes No

Do you provide specialized services to specific populations?

People with Health Conditions/Disabilities People Experiencing Homelessness Older Adults Immigrants/Refugees/Asylum Seekers Transition Aged Youth People Experiencing Intimate Partner Violence Veterans/Military People with a serious mental illness Individuals in the LGBTQ+ Community Other

What area(s) of need do your services address?

Does your business offer a sliding scale if there are fees to the client/patient?

How does your business address grievances from clients/patients?

What is the accrediting or licensing entity for your business’ services?

Who does your agency contract with (e.g county, cities, other)?

Are any of your direct services provided by subcontracted providers?

Yes No

Please provide two community based organizations that can serve as a reference on your behalf.

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