Request to Add Resource to Database

Request to Add Resource to Database
This form has been moved to here: https://linesforlife.jotform.com/241616470244048
Your Name*

First NameLast Name
Your Email*
example@example.com
Name of Resource*
Alternate Name (if applicable)
Physical or Mailing Address(es) (if applicable)
Phone Number(s) (if applicable)
Email Address (if applicable)
Website Address (if applicable)
Description*
Coverage Area (if applicable)
Eligibility (if applicable)
Fee Structure (if applicable)
Languages (if applicable)
Categories (Please check all that apply)*

Alcohol and DrugAdvocacy/EducationChronic Pain ManagementCrisis Lines/Resource LinesCulturally-Specific ResourcesDisabilitiesDomestic Violence/Sexual AbuseEating DisordersEmergency ServicesFinancial supportGambling treatment servicesHospitalsHousingMedical/DentalMental HealthMilitary and VeteranOnlineSupport Groups/CommunityYouth
Alcohol and Drug Subcategories (Please check all that apply)

Advocacy/EducationDetoxDiversion/DUIIDrug TestingDrug-Free HousingDual DiagnosisEvaluationsInpatientInterventionsMethadoneOutpatientSuboxoneYouth Tx
Advocacy/Education Subcategories (Please check all that apply)

DisabilityMental HealthYouth
Crisis Lines/Resource Lines Subcategories (Please check all that apply)

Alcohol and DrugCounty Crisis LinesDomestic ViolenceHealthMental HealthYouth
Culturally-Specific Resources Subcategories (Please check all that apply)

Race/EthnicityDisability/AbilityGender IdentityLGBTQ+Other
Domestic Violence/Sexual Abuse Subcategories (Please check all that apply)

Abuser intervention treatmentSurvivor's Services
Emergency Services Subcategories (Please check all that apply)

FoodHospitalsPoliceShelterWalk-in
Hospitals Subcategories (Please check all that apply)

Domestic ViolenceDrug-FreeEmergency ShelterFoodLow-CostOtherTransitionalYouth
Medical/Dental Subcategories (Please check all that apply)

AdultYouth
Mental Health Subcategories (Please check all that apply)

Advocacy/EducationCounselingHospitalizationsLow CostOutpatientResidentialSenior Community IntegrationSupport GroupsWalk inYouth
Military and Veteran Subcategories (Please check all that apply)

Benefits/EligibilityCaregiversCounseling/Mental HealthCrisis & Resource Lines/DirectoriesEducationEmergency ServicesEmploymentFamilyFinancial Issues (various)Homeless resourcesInternationalLegal (Personal, AWOL/Discharge, etc)Multicultural/IntersectionalPTSD TreatmentReintegration SpecificResource Locators/SitesSubstance abuseSuicide Prevention CoordinatorsTransportationVA Healthcare (VAMCs/Vet Centers/CBOCs)Vet Organizations/AdvocatesVeteran Service OfficersWellness Programs for Veterans
Support Groups/Community Subcategories (Please check all that apply)

AddictionAlternatives to 12 StepDomestic ViolenceLGBTQ+GriefMental HealthYouth
Youth Subcategories (Please check all that apply)

Alcohol and DrugEmployment/EducationHealthHigh SchoolHousingLegalLGBTQ+MedicalMental HealthOnlineParentingRecreationReporting/Abuse
Should be Empty: