Intake for Non-Profit Agencies/Program

Today's Date*

MonthDayYear

Complete one form per program. Please keep the description short but comprehensive in listing your services. Helpline and 211 Information and Referral Database staff reserve the right to edit information to match our style guidelines.

Agency Info*

Primary Contact Phone Number*

Do you want this phone number marked as private (not viewable by the public)?*

YesNo

Primary Contact Email*

example@example.com

Do you want this email marked as private (not viewable by the public)?*

YesNo

Are you the Agency Senior Administrator?*

YesNo

Senior Administrator Email:

example@example.com

Do you want this email marked as private (not viewable by the public)?

YesNo

Senior Administrator Phone Number

Do you want this phone number marked as private (not viewable by the public)?

YesNo

Generic/Main Email for listing*

example@example.com

Generic/Main Phone Number for listing*

Website for listing

example@example.com

What year was the agency incorporated (if unknown, enter N/A)*

What type of program/agency/group is this?*

Agency Mission Statement . *

Where does agency/program serve, check all that apply:

Description of program/services. Please be specific and concise; written in neutral/3rd party/non-marketing language:*

Eligibility (i.e. Children, Elderly, Open to all)::*

Intake/Application Process (i.e. Walk-in, Online, Call to set up an appointment, none, etc.):*

If any part of your intake process requires the client attend in-person, are all of your locations ADA compliant? *

Documents Required (ie. ID card, SS card, None, etc.):*

Does this resource accept donations of certain items? The 211 resource database will not list "Accepts monetary donations" or "Donations of time/volunteers" on any record:*

Is this program offered at multiple sites?*

YesNo

If yes, please list information for other locations:

Site Name Street Address Address Line 2 City State Zip

If more than three additional sites, please list below:

Please upload a copy of your most current brochure:

This signed release form will be kept on file as an ongoing authorization that Helpline may provide information to the public regarding the above-mentioned agency/organization. In addition to relaying information over the telephone, HelpLine also disseminates information in a variety of printed and electronic formats including, but not limited to, human service directories, community resource sections in telephone books, computer disks, the Internet, and mailing lists/labels.

The above-mentioned agency/organization agrees to inform HelpLine of any changes or discrepancies it makes or discovers and is solely responsible for keeping HelpLine informed of changes, which may be needed in the information. This agency agrees to provide Helpline with updated information when it is requested.

This document shall be considered in place and valid until such time as the above-mentioned agency informs Helpline in writing that it is terminated.

Helpline has an inclusion policy that states “inclusion in the HelpLine database should in no way be construed to constitute an endorsement of an agency or organization or its service, nor should exclusion be construed to constitute disapproval. The information that appears in the Helpline database is provided by the agencies and organizations. We make no representation with respect to the completeness of the information. Helpline reserves the right to remove or exclude any organization from the Helpline database for any reason. Inclusion in the HelpLine database is a privilege rather than a right.”

Signature

Print Full Name

First NameLast Name

General Agency/Program Info and Primary Contact

Agency Senior Administrator Info (if not primary contact):

Public Listing Information

Release