Mainstay - Proactively improving the health of people with developmental disabilities and the organizations that support them.

Fiore™ Partner Application

Please complete the information below and follow the instructions at the bottom of the form to submit your confidential application.

If you have a PDF copy of your agency's most recent annual report, we're interested in reviewing this information in order to understand more about your unique mission and vital organization. Please send your annual report to: partner@e Mainstay.com

Thank you, and we will respond promptly.



Name and title of person completing application

Name of organization

Address

City

State

Zip

Web address

Founded in what year

Name of Executive Director

Contact phone number

Contact email address

Total revenue

Number of people (customers) supported

Number of full-time equivalent direct support staff

Number of people receiving residential supports

Number of 24 hour staffed community-based group living locations, with:

1–3 customers 4–6 customers 7–10 customers 11–16 customers

What are the above homes licensed as?

Development revenues (in millions)

What are your mission and primary business challenges?

Privacy/Legal