Application for CalAIM Initiatives

Instructions:
Thank you for your interest in this program. Please fill out this application form completely. All information provided will be kept confidential. Once your application is reviewed, you will be contacted.

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Name

Email Address

Date of Birth

Member ID Number AND Insurance Company (Molina, IEHP or Kaiser Only)

Phone

Address (Current or Last Known)

How did you hear about us?

Are you looking to apply for one of our remote positions (work from home)?

Have you been affected by the recent fires in LA County?

Are you currently experiencing homelessness for and danger of becoming homeless? Yes or no? If yes, what county are you in?

Are you or anyone in your household approved for a housing choice voucher or project based voucher? Yes or no

Are you experiencing any serious chronic physical or psychological conditions? Yes or no

Are you currently or were you recently institutionalized in long-term care, hospitalization or similar? Yes, or no

You can send to receiving service related SMS messages. You may opt out by replying stop.(required)

Yes

E-Signature and Agreement:

By submitting below, I confirm that the information provided in this application is true and accurate to the best of my knowledge, and this will be considered my consent and signature. I understand that participation requires a commitment to the training, education, and support services provided. I also understand I must meet all eligibility requirements to be considered. SUBMIT BELOW

Thank you for your interest in the! We look forward to reviewing your application and discussing how we can support you on your journey to health and success with us.