New Agency Survey Form

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Main Agency Street Address





Mailing Address (skip if same as above)













Agency Director






Agency Contact (This should be the person 211 will contact for updates)






Alternate Contact























Page 2 of 3
If your agency has only one location, please skip down to section H.
A. Secondary Location Information






B. Secondary Location Mailing Address





C. Secondary Location Contact Information



D. Site Coordinator Information






E. Site Contact Information














Programs/Services Offered at this Site:

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). 


Service contact person:
  name, title, telephone number and email of person to contact regarding service.Click here to enter text
Program Details













211 requires that you certify your application by submitting an electronic signature. To certify your application, read the text below and provide an electronic signature (check the box provided) and click Confirm Submission