Lead Form

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DESCRIPTION / IMPORTANT NOTES:

Applicant Liaison Name:
Relationship to Applicant (Title):
Name of POA:

PLEASE FILL OUT A VALID EMAIL ADDRESS, THE FORM WILL NOT CREATE A LEAD IN INSIGHTLY.
IF THE CLIENT DOES NOT HAVE AN EMAIL... Use the client's FirstNameInitialLastNameFAKE@gmail.com email. DO NOT USE THE SAME FAKE EMAIL OVER AND OVER they need to be different fake emails.
ONLY PLACE ONE EMAIL NOT MULTIPLE EMAILS.

Email:

Mobile Phone:
Home Phone:

Applicant First Name:
Applicant Last Name:

Lead REF Contact:
Lead REF Organziation:
Lead REF Event:

Age:
Marital Status:
Living Status:

Applicant Income:
Spouse Income:

Checking / Savings:
Investment / Retirement Accounts:

Insurance or Burial Policy:

Property:
Address:
County:

Trust:

Vehicle:

Initial Meeting Format:

Comments

Helpful Referral Notes

DHS: Someone already on Medicaid with Medicaid questions. Received denial, ask more questions to determine if they need us or DHS.

- https://cdhs.colorado.gov/contact-your-county (link for all DHS’ in the State of Colorado)

TRE/SEP: Already have benefits but want to start services.

- The Resource Exchange (TRE) 719-380-1100

- https://hcpf.colorado.gov/single-entry-point-agencies (link for all SEPs in Colorado)

AAA: No resources, citizenship requirements not met, qualify on their own but need help with application.

Lead Form

Helpful Referral Notes

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