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Quote Generation Questionnaire
Name
*
First
Last
Phone
*
Email
*
Company Name
*
What services are you interested in?
*
Therapy ( Session notes, documentation, e-signature)
Billing
HR (Timesheets, Invoices, Clearances, Continuing Education)
Number of Therapist Users
*
Number of Admin Users
*
2 are included, additional users are charged at $24.50/admin/month
Current number of children seen per month
Current number of services per month
In what states do you provide services
*
Pennsylvania
List all counties in which you provide services
*
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Select Disciplines
*
Physical Therapy
Occupational Therapy
Speech
Vision
Nutrition
Social Work
Nursing
Other
Will you be using the Zoom Video Integration
*
Yes
No
The Zoom integration requires a HIPAA compliant Zoom account, with individual users.
When are you looking to start using your new system?
*
4-6 weeks
7-12 weeks
More than 12 weeks
How want to enter current or past client information
*
Self Manual Entry (Free)
Data Import (Current Clients Only) - Quote
Data Import (Current and Historical Data) - Quote
Will you require additional training?
*
No, included training is sufficient
Yes, I require additional training sessions - Quote
Included: Admin: 1 training prior to launch, and 2 training after launch Therapist: 1 training prior to launch, 1 training after launch
What level of support do you require?
*
Up to 10 tickets per month (free)
I require more support - Quote
Will you be paying monthly or annually?
*
Monthly
Annual
Subscriptions are charged on the first of the month. Annual subscriptions give a 2 month discount. Setup and Data Migration fees at are charged at signup.
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