Contact Form
Please fill out as many of the blanks below as possible so that we may tailor a demonstration specific to your agency.
A KaleidaCare representative will contact you shortly.
Contact Information:
Salutation:
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Mr.
Ms.
Mrs.
Dr.
Prof.
First Name: *
Last Name: *
Title: *
Company: *
Website:
Email: *
Phone: *
Address:
City:
State:
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Alabama
Alaska
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Colorado
Connecticut
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District of Columbia
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South Carolina
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Tennessee
Texas
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Vermont
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Washington
West Virginia
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Alberta
British Columbia
Manitoba
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Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Virgin Gorda
Outside US and Canada
Zip/Postal Code:
Country:
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USA
Canada
Other
Agency Information:
How did you hear about us?
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Advertising
Referral
Conference
Direct Mail
Web Site
Other
What is the best way to reach you?
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Phone
Email
Mail
When does your budget cycle start?
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January
February
March
April
May
June
July
August
September
October
November
December
What is your annual IT Budget?
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<$15,000
$15,000-25,000
$25,000-30,000
>$30,000
Don't know
How many active clients do you currently have? *
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0-50
51-100
101-250
251-500
>500
Are you currently using a client management system?
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No
Yes
If so, what software product are you using?:
What is your expected timeframe for new system implementation?
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0-3 months
3-6 months
6-12 months
>12 months
Not sure
Please check all the programs/services offered by your agency: *
Adoption Services
Counseling Services
Family Preservation
Foster Care
Independent Living
Residential Treatment
Community Based Services
Crisis Intervention Services
Family Support Programs
Group Home
In-Home Services
Shelter Care
Please let us know if you have any specific comments or questions (240 characters maximum):
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