Service Area: Indicate the counties, cities or zip codes each program serves.
Other Sites: Indicate other sites that also provide this service.
Service Hours: Indicate the times service is offered, if different from site hours.
Eligibility: Who is eligible for the service? Do you restrict the service to certain populations based on gender, age, income guidelines, disability, etc. (e.g., battered women with children, people with visual impairments, youth 5 to 12)?
Intake/Application Process: walk in for service, telephone, appointment only, referral required, etc.
Fees and Payment Types: no fees, suggested donation or straight fee (include $ amount), sliding fee scale (include range), payment types accepted: Medicare, Medicaid, private insurance or call for details.
Required Documentation for Service: none, picture ID, Social Security Card, birth certificate,proof of income, proof of residence, eviction notice, driver’s license, medical/psychiatric records, shut-off notice, case worker referral or other documents (specify).