Partner Interest Form

*Your Name:

*Your title:

*Email address:

*Organization name:

*Organization address:

*City:

*State:

*Zip code:

*Country:

*Telephone:

Ext:

Fax:

What is the primary focus of your business?

	Reseller / Distributor
	Systems Integrator
	Consulting Services
	Software Development
	Hardware Provider
	Application Service Provider (ASP)
	Content Provider
	Other (please describe in the box below)

How many employees are in your company?

What is your estimated Annual Revenue?

How long have you been in business?

What geographic area does your organization serve?

What segments of the Behavioral Health and Health and Human Services markets/ programs do you serve?
(check all that apply)I

What type of partnership are you interested in forming with Netsmart Technologies?

Please describe your partnership strategy with Netsmart Technologies

Do you have a customer opportunity that would involve Netsmart Technologies or an existing mutual customer?

	Yes
	No
	If yes, please describe the opportunity in the box below

Helper, the leading practice management and e-prescribing solution for psychiatrists,
psychologists, counselors, social workers and therapists.