Resource Data Form for Louisiana 211

Louisiana 211 Resource Submission Form

Please complete this form and your information will be provided to the regional Louisiana 211 organization(s) for the geographic area indicated for this program. If more information is needed, we will be sure to reach out to you. Thank you for sharing this information with Louisiana 211.
Information

(For questions that do not apply, please respond n/a)
Agency/Program Name:*
Physical Location:*
Mailing Address:*
Phone #s:*
Agency Type:*

Battered Woman's SheltterBusiness AssociationCity/Parish GovernmentDomestic ViolenceEducationalFaith-Based Non-ProfitFederal GovernmentFor-ProfitHomeless SheterHospital/MedicalLegalMental HealthNon-ProfitPrivate IndividualPrivate, Non-ProfitPublic Housing AuthorityPublic ServicesState GovernmentSubsidized Rental HousingTransitional ShelterUnited WayVeteransVolunteerYouthOther
Contact Information:*
After Hours Contact Information:
Describe what your program is and the services it offers to individuals. *
Directional Landmarks that may help us describe your location for services:(example, “South of the main library”):*
Is your agency Handicap Accessible?*

YesNo
Regular Office Hours of Operation:

(Please indicate am/pm in your submission. Example: 7 am)
Sunday: From Sunday Start Time*(am/pm) to Sunday End Time* (am/pm)
Monday: From Monday Start Time*(am/pm) to Monday End Time* (am/pm)
Tuesday: From Tuesday Start Time*(am/pm) to Tuesday End Time* (am/pm)
Wednesday: From Weds. Start Time*(am/pm) to Weds. End Time* (am/pm)
Thursday: From Thurs. Start Time*(am/pm) to Thurs. End Time* (am/pm)
Friday: From Friday Start Time*(am/pm) to Friday End Time* (am/pm)
Saturday: From Sat. Start Time*(am/pm) to Sat. End Time* (am/pm)
Description of Office Hours (i.e. Closed for lunch, 12-1 pm) Description of Hours
Service Area Information:*
Fees/Charges:*

No Fees/ChargesStraight Fee (specify details below)Sliding Fee Scale (specify eligibility and range details below)Other
Fee Details:
Types of Insurance Accepted:

MedicareMedicaidPrivate Insurance
Intake Procedure:*

Walk InTelephoneAppointment OnlyReferral required (specify by whom below):
If a referral is required (please specify by whom below):
Eligibility:*
(example, ‘homeless men’, ‘battered women and their children’, ‘HIV+ adults’, ‘visually impaired’, etc):
Required Documentation:*

None RequiredPicture IDSocial Security CardProof of Residence
Services are consistently provided in the following languages:*

EnglishSpanishViatameseAmerican Sign LanguagesOther
Is language interpretation services available?

YesNo
The above described agency is operating legally, with both facilities and staff that are licensed and credentialed to provide the services offered. We offer services that are available to the general public of Louisiana and are not limited to members of specific groups or organizations. This organization meets 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.
Authorized Signature*
Authorized Agency Signature*
Should be Empty:

Louisiana 211 Resource Submission Form

Information