Demo Request -- Organization Info

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ORGANIZATION INFO

First Name

Last Name

E-mail Address

Cell Phone

Job Title

Account Manager

Admin Assistant

Administrator

CEO

CFO

CIO

Clinical Director

COO

Corporate IT

CTO

Dir. Nursing

Former Contact

HR

IT

Marketing

MDS Coordinator

Nurse

Office Manager

Owner

Pharmacist

Pharmacy Tech

President

Program Director

Receptionist

Secretary

Therapist

Vice-President

Regional - Wellness/Nursing

Regional - Operations

Operations Manager

Other

Executive Director

Organization Name

Organization Type

Adoption

Assisted Living

Assisted Living

Independent Living

Alzheimers Care

Residential Care

Personal Care

Sheltered Care

Association

Behavioral

Behavioral

Behavioral - Troubled Youth

Behavioral - Therapeutic School

Behavioral - Addiction Recovery

Behavioral - Counseling

Behavioral-Wilderness Therapy

Behavioral-(IOP)Intensive Outpatient

Behavioral-(OP)Outpatient

Behavioral-(PHP)Partial Hospitalization

Behavioral - Other

Behavioral-Eating Disorders

Behavioral-Residential Treatment

Skilled Nursing

Skilled Nursing

Skilled Nursing - LTC only

Skilled Nursing - Short Stay only

Skilled Nursing - All

Troubled Youth

CCRC (SNF, ALF, IND)

Collaboration/Training

Counseling

Ed Inst

Faciliq

Foster Care

Gov't Sub-con

Government

Handicapped

Home Care

Hospice

Outpatient

Pharmacy

QualityReview

Recovery

Rehab

Retail

Web Host

Women's Shelter

Other

VAR - Other

IDD

MeSA

BlueStep Translate

BlueStep Translate

Trading Partner

Number of Locations

Number of Beds
Total

Address

City

State

Zip Code

Work Phone

Web Site

How did you learn about BlueStep?

How are you currently charting/documenting?

On Paper

Electronically

Explain

Have you evaluated a QIS system in the past?

Yes

No

Explain

Sales Rep Name
If applicable

Best days for a demo?

Su

M

Tu

W

Th

F

Sa

Time

Morning

Afternoon

Either

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