agency survey FORM

LOCATION

Street City Zip

Is the physical address confidential?  No Yes

If the mailing address is different than the physical address, please indicate below:

Street City Zip

AGENCY CONTACT INFORMATION

Main Contact Phone

TDD/TTY  

Web Site:  

Email:  

Hours of Operation

Regular Office Hours 1 2 3 4 5 6 7 8 9 10 11 12 :00 :15 :30 AM PM     TO  1 2 3 4 5 6 7 8 9 10 11 12 :00 :15 :30 AM PM

DAYS: Monday  Tuesday Wednesday  Thursday Friday Saturday Sunday

If applicable, please list special services that have limited hours/days or special intake hours:

Eligibility

Who is eligible for your services? It is acceptable to restrict services to certain populations based on gender, family status, disability, personal situations, etc. (i.e. battered women with children, people with visual impairments or homeless men, etc.) This will assist us in making appropriate referrals to you.

Service Description

Please list the primary services offered to individuals meeting your eligibility requirements. Please be as detailed in your description as possible; Please mail us any pamphlets/other information, as applicable.

Service: 

What are your intake options?

Walk-In  Telephone Appointment Only

Referral Required?   No Yes   If yes, by whom? 

Program Capacity

Number of People program can serve:

Program Affiliation

Is program affiliated with national org.?   No Yes   If yes, with whom?  

Licensing/Accreditation

Service Area

Please indicate the area(s) you serve

Fees

Are individuals charged for your services?   No Yes  

Straight Fee?  Yes No Please Specify:

Sliding Fee Scale?  Yes No Please specify eligibility and range:

Method of payment accepted:

Languages

In addition to English, what languages does your staff speak?

Spanish  American Sign  Other:  Literature available in Spanish

Required Documentation

None Required Picture ID Social Security Card

Proof of Residency/Lease Proof of Income Birth Certificate

Medical or Psychiatric Records

Other

Public Transportation

Is your facility within 3 or 4 blocks of public transportation? Yes No

If Yes, please indicate stop location 

Accessibility

What accommodations does your facility provide to people with disabilities as

defined by the Americans with Disabilities Act (ADA)?

Elevators Indoor Wheelchair Access Designated Parking Outside Ramp None

Please indicate your organizational status

Federal   State   County City

Non-Profit/Religious Non-Profit Other For-Profit  

Volunteer Opportunities

Does your organization offer volunteer opportunities?   Yes No

If Yes, please provide the following information:

May we list your organization as accepting volunteers at this time?   Yes No

When do you have volunteer opportunities?

What type of opportunities are available?

Minimum age to volunteer:   Do you accept groups as volunteers?  Yes No

Do you accept families with children as volunteers?  Yes No

Do you accept court ordered volunteers?  Yes No

Do you have seasonal volunteer opportunities for Thanksgiving,

Christmas or other holidays?  Please specify:

Volunteer Coordinator or Contact:   Phone:

Does your organization discriminate in providing service or volunteer opportunities based on race, ethnicity, sexual orientation or religion?

Yes No

If your organization meets the criteria to be included in our written products,

website or publications, do you wish to be considered for inclusion?

Yes No

To the best of my knowledge, all of the preceding information is true and accurate.

Name:    Title:    Date: