FACILITY NAME:PHONE:

ADDRESS 1:

CITY:

CONTACT:

FAX:

ALTERNATIVE CONTACT:

FAX:

ADDRESS 2:

STATE:

TITLE:

MOBILE:

TITLE:

MOBILE:

ADDRESS 3:

ZIP:

PHONE:  (EXT.)

EMAIL:

PHONE:  (EXT.)

EMAIL:

FACILITY TYPE

POPULATION RECEIVING SERVICE

SKILLED NURSING FACILITY

HOSPITAL

PRIVATE SCHOOL

SCHOOL DISTRICT

ADULT DAY CARE

PRIVATE PRACTICE

GROUP HOME/RESIDENCE

HOME CARE ADULT

CURRENT THERAPY VENDOR(S)

HOW LONG?

HOW LONG?

HOW LONG?

WHAT TYPE OF SERVICE IS/ARE YOUR CURRENT VENDOR(S) PROVIDING?:

 FULL SERVICE (STAFFING & MANAGEMENT)       STAFFING        CONSULTING     MANAGEMENT 

CURRENT STAFFING PATTERN:PLEASE ENTER TOTAL NUMBER OF STAFF CURRENTLY IN EACH DISCIPLINE:

PT 

PTA 

OTR 

COTA 

SLP 

NEW STAFFING PATTERN:PLEASE ENTER THE TOTAL NUMBER OF STAFF IN EACH DISCIPLINE, YOU BELIEVE YOU NEED TO MAKE YOUR PROGRAM MORE SUCCESSFUL:

PT 

PTA 

OTR 

COTA 

SLP 

SERVICE(S) YOUR FACILITY IS MOST INTERESTED IN:

 FULL SERVICE (STAFFING & MANAGEMENT) {APPLIES TO LONG TERM CARE AND ADULT DAY CARE FACILITIES ONLY}
 STAFFING        CONSULTING      MANAGEMENT 

WHY ARE YOU DISSATISFIED WITH YOUR CURRENT PROVIDER(S)

WHAT MUST NURSEWORKS DO TO BE SELECTED AS YOUR NEW REHAB PROVIDER?

HOW DID YOU HEAR ABOUT NURSEWORKS?

WORD OF MOUTH

TRADE SHOW/SEMINAR

CLIENT REFERRAL (ALREADY WORKING WITH NURSEWORKS)

INTERNET

NURSING REFERRAL

VTA-NURSEWORKS WEBSITE

SPACE ADVERTISING

TELEMARKETING

DIRECT MAIL (FLYER/BROCHURE/POST CARD)