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: