
232-HELP/211
Resource Information Survey
P.O. Box 52763 } Lafayette } LA } 70505
Email: help@232-help.org } Fax: (337) 232-1960
Web Site: www.232-help.org
For the benefit of your agency/organization and the clients you serve, please fill out completely. For items not applicable, indicate so with N/A.
Program Name:
Street Address:
City: State: Zip:
Mailing Address (if different):
City: State: Zip:
Phone Numbers: Caller Referral:
Administrative:
Fax:
Web Site: E-Mail Address:
Federal ID Number (EIN):
Operating Agency (if different from program):
Mailing Address (if different from program):
City: State: Zip:
Type of Agency: Public/Governmental Non-Profit Private Business
Religious School/University Volunteer
Other (please specify)
Chapter or Affiliate of a National Organization? If yes, name:
Name & Title of Person in Charge:
Days/Hours of Operation:
Fees/Charges (If Any):
Accept Medicaid: Yes No; Accept Medicare: Yes No
Other Payment Methods Accepted:
Any Financial Assistance Available:
(payment plan, sliding scale, etc.)
Geographic Area Served: City Parish Acadiana State Nationwide
Language Capabilities:
Intake Procedure ( application required, interview process, needed documentation?):
Eligibility Requirements (Please be specific):
Program Information:
Please give detailed program description. If more than one program, copy the survey and complete one for each additional program.
Program Description:
Signature: Date:
Title: