232-HELP/211

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?):

___________________________________________________________________________________

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: _________________________________________