Agency Information Form
Legal Agency Name:
Other names (AKA, acronyms, former, etc.):
Director Name/Title:
Other Contact Name/Title:

1. Location: What is the physical address of your organization?
(Please photocopy and complete a separate form for each additional branch.)

Address:
County: City:
State: Zip Code:
Administrative Telephone:
Admin. Fax:
Is the physical address confidential? Yes No

Is the mailing address the same as the physical address? If not, please indicate mailing address below.

Address:
City: State:
Zip Code:

2. Client Contact Information:

Main Telephone given for Clients: Fax Number:

TDD (Telecommunication Device for the Deaf) Number:

E-Mail: Website:

3. Regular office hours: am/pm to am/pm
Days: Mon Tue Wed Thu Fri Sat Sun

Please list special services that have limited hours/days or special intake hours if applicable.

4. Eligibility: Who is eligible for your services? It is okay to restrict services to certain populations based on gender, family status, disability, personal situations, etc. (i.e. battered women with children, or people with visual impairments, or homeless men, etc.) This helps us make appropriate referrals to you

5. Service Description: Please list the primary services offered to anyone meeting your eligibility requirements. Please be as detailed in your description as possible; attach additional pages, or any pamphlets/other information as applicable.

What secondary services are offered only to establish clients? For example: resume-writing only for the participants in a job-training program; meals only for shelter residents; clothing only for women in a welfare-to-work program.

6. Intake: What are your intake procedures?

Walk-in Telephone
Appointment: For what services? Referral Required: By whom?

7. Service Area: Please indicate the area where your agency provides services.

8. Fees: Are individuals charged for your services? What is your fee structure?

No Fee Straight Fee; please specify
Sliding Fee Scale; please specify eligibility and range

9. Languages: In addition to English, what languages are routinely spoken by your staff?

Spanish American Sign Language
Literature/information available in Spanish Other; please specify

10. Required Documentation:

None Required Picture I.D.
Social Security card Proof of residence
Other  

11. Directions: Please provide, basic directions to your facility (unless confidential – e.g., battered women’s shelter).

12. Public Transportation: Is your facility within 3 or 4 blocks of the public transportation?

Yes No
Stop name:

13. Agency Transportation:

Agency provides transportation Agency will arrange for transportation
Agency will conduct home deliveries Special Conditions:

14. Accessibility: What accommodations does your facility provide to people with disabilities as defined by the Americans with Disabilities Act (ADA)?

Designated parking Indoor wheelchair access Outside ramps Elevators

None

15. Please check the one answer that indicates your agency’s organizational status.

Federal (F) County (C) Non-Profit/Other (N) For-Profit (P)
State (S) City (M) Non-Profit Religious (R)  

501c3 or For-profit Business License Number (if applicable):

16. If your organization meets criteria to be included in our written products or publications, do you wish to be considered for inclusion? Yes No

17. Does your organization discriminate in providing service or volunteer opportunities based on race, ethnicity, sexual orientation or religion? Yes No

211 would like to establish an ongoing relationship with a key person in your organization who can be contacted for updates, and who will contact us with relevant agency changes. Please indicate who that key person is.

Name/title:
Phone Number:

We meet all Federal, State and Local laws, requirements and regulations including fire, health and zoning codes. To the best of my knowledge all of the preceding information is true and correct.

 

Thank you for your time in completing this information sheet. This valuable information will be used to communicate your offerings with the general public and personnel from other agencies. Questions, comments, and suggestions may be communicated by mail at the address listed above or by telephoning our offices at 229-245-8064. We look forward to hearing from you.