232-HELP/211

2006-2007 Resource Information Survey

P.O. Box 52763  }  Lafayette  }  LA  }  70505

                        Email: help@232-help.org   }  Web Site:  www.232-help.org   }  Fax: (337) 232-1960

 

 

 

 

 

 

 

 

                                      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:         Referrals ______________________________________________________

                                   

                                    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?):

 

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Eligibility Requirements (Please be specific):_____________________________________________

 

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Program Information:

 

Please give detailed program description.  If more than one program, copy the survey and complete

one for each additional program.

 

Program Description:___________________________________________________________________

 

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Signature: _________________________________________     Date:________________________

 

Title:    _________________________________________