Legal Agency Name: 

A.K.A : 

Legal Organizational Status: Federal   State   Non-Profit    Non-Profit Religious   County

                                        City   Other

General Agency Description:

Director's Name/ Title:

Service Area: Choose the one type of area that most reflects you clientele.

Statewide   East Tennessee   Specific Zip Code   or specific County/Counties 

Funding Sources:

Location(s): (If you have more than one location please enter all other locations here, otherwise enter main location here)

Is the physical address confidential? YES   NO

Physical Address:

Mailing Address:

City:   State:   Zip Code:   County:

Contact Information:

Main number: ()         -        FAX: ()         -    Toll Free: 1-()         -

TDD/TTY Number:        

EMAIL Address:     Website: http://www.

Languages:

 In addition to English, what languages are your staff speak fluently?

American Sign:   Spanish:   Tele-Interpreter Services:   Other:

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 Ramps:   Wheelchair Lifts:

No Access:

Hours of Operations:

Regular office hours:AM-PM      Days: Mon   Tue   Wed   Thurs   Fri   Sat   Sun

If your hours vary during the week please note here

Average wait time for services ( if any) (enter estimate in hh:mm format): :

Volunteer Opportunities:

Does your organization accept volunteers from any of the following?

Youth ages 12-17:   Court Ordered:   Seasonal (Thanksgiving or Christmas):   Other:

Volunteer Coordinator:     Phone: () -   EXT:

Donations:

Does your organization accept ongoing, non-monetary donations in support of programs or services? (Example: pet food, clothing, appliances, furniture, food pantry items)

If yes, please please list:

Do you provide a pick-up service? YES   NO    If so, area served:

Do you accept donations in need of repair? YES   NO

Donations Coordinator:   Phone: ()         -   EXT:        

Description of Services:  Please enter information for each service you provide, primary services here then enter other services along with eligibility requirements, application process, fees, and required documents here.

Service #1:

Full Description:

Service #2:

Full Description:

Service #3:

Full Description:

Eligibility:

Who is eligible for your services?  Is it okay to restrict services to certain populations based on gender; family status; disability; age; personal situations, etc. (i.e. battered women with children, people with visual impairments, homeless men, etc.) This helps us to make appropriate referrals.

Service #1:

Eligibility Requirements:

Service #2:

Eligibility Requirements:

Service #3:

Eligibility Requirements:

Application Process:

How would someone apply for each service?

Service #1:

Walk-in:   Telephone:   Appointment only:   Referral Required:   By Whom:

Service #2:

Walk-in:   Telephone:   Appointment only:   Referral Required:   By Whom:

Service #3:

Walk-in:   Telephone:   Appointment only:   Referral Required:   By Whom:

Fees:

Are individuals charged for your services?  What is you fee structure?

Service #1:

No Fee:   Straight Fee (please specify):

Sliding Scale Fee:   Insurances:  Medicaid   TennCare   Private

Service #2:

No Fee:   Straight Fee (please specify):

Sliding Scale Fee:   Insurances:  Medicaid   TennCare   Private

Service #3:

No Fee:   Straight Fee (please specify):

Sliding Scale Fee:   Insurances:  Medicaid   TennCare   Private

Required Documents:

What documents would someone need to bring when applying for your service?

Service #1:

No Documents   Picture ID   Social Security Card   Proof of Residence   Proof of Income  

Birth Certificate   Medical or Psych Records

Service #2:

No Documents   Picture ID   Social Security Card   Proof of Residence   Proof of Income  

Birth Certificate   Medical or Psych Records

Service #3:

No Documents   Picture ID   Social Security Card   Proof of Residence   Proof of Income  

Birth Certificate   Medical or Psych Records

Are there other agencies or services that have been helpful that you would recommend to be included in our resource database?  If so, please provide contact information for these agencies/services.

BY FILLING OUT AND SUBMITTING THIS FORM YOU ARE GIVING CONTACT-CONCERN YOUR PERMISSION TO INCLUDE YOU IN OUR RESOURCE DATABASE