This survey will help us to direct appropriate referrals to your agency. Please make sure to fill in the survey as completely as possible. Thank you for your cooperation!
Organization’s Legal Name:
______
AKA (if applicable):
______
Address:
______
Mailing Address (If Different):
______
Travel Instructions (Example: Two blocks south of First and Main Street, across from the Post Office):
______
Is there public transportation to this location? q Yes q No
Telephone: (_____) ______ext. ______
Toll-Free: (_____) ______ext. ______
FAX: (_____) ______ext. ______
TDD/TTY: (_____) ______ext. ______
Other: (_____) ______ext. ______
Hours: ______
Agency Director/Title:
______
Phone: (_____) ______ext. ______
Email Address: ______
Agency Contact Person/Title:
______
Phone: (_____) ______ext. ______
Email Address: ______
General Information
Please mark the category/categories that best describes your organization.
q Church Affiliated q Coalition/Other Group
q Private/Non-Profit q Proprietary
q Public – City q Public – County
q Public – Federal q Public – State
q Special District q Other, as follows: ______
Facility Type
Please mark the category/categories that best describes your organization.
q Church q Clinic/Hospital q County Office
q School q Private Practitioner q Other, as follows: ______
Website Address: ______
General Email Address (e.g. ): ______
Federal ID (EIN) # ____________
Year Incorporated: ______
Accessibility:
q Designated Parking q Ramps
q Elevators q Full Wheelchair Access
q Limited Access q Lowered Elevator Controls
q No Access q No Stairs in Service Area
q Not Applicable q Other ______
Funding Info:
q Corporation q Donations q Fees
q FEMA q HUD q Independent Fundraising
q JTPA q City Funding q County Funding
q Private Funding q State Funding q United Way Funding
Administrative Description/Mission:
______
Administrative Hours:
______
______
Program/Service Name: ______
Program/Service Description: (attach additional sheet(s) as necessary):
______
Program/Service Location (Please check and list the location(s) at which this program/service if offered):
q Site 1: Main/Administrative Office
q Site 2: ______
q Site 3: ______
q Site 4: ______
q Site 5: ______
Program/Service Contact Information (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
Program Hours:
______
q Check here if this service is not available year-round or on a consistent basis. Explanation: ______
Application: q Referral Required From: ______
q Appointment Required
q Walk-Ins
Documentation Required (Photo ID, Proof of Income or Residence, etc.):
______
Eligibility Requirements (Income, Age, Gender, Location, etc.):
______
Fees/Payment Methods (Set fees, Sliding scale, Medicaid, Medicare, etc.):
______
Languages Offered: q English q Other, as follows: ______
Waiting List for Service: q Yes q No
Form Completed By (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
Date Completed: ______
q Check here to be included on the 2-1-1 Community Announcement list-serv.
Has 2-1-1 expanded your knowledge of community resources?
q Yes q No, please explain. ______
Contact for Future Organizational Updates/Surveys, If Different (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
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Thank you for taking the time to provide this information. Your responses will help us to better meet the needs of the people in our communities.
If you have questions or comments, contact:
Central Michigan 2-1-1
Toll-Free (866) 561-2500
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For Administrative Use Only
Date info taken: ______
Staff/Volunteer receiving info: ______
Date entered into database: ______
Entered By: ______
Record Number: ______
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Central Michigan 2-1-1 Revised 10/10/2013
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Please mail the completed form to:
Central Michigan 2-1-1 Revised 10/10/2013
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For Clinton, Eaton, Hillsdale, Ingham, Jackson, Lenawee or Livingston County:
Jessica Embury
LifeWays
1200 N West Ave
Jackson, MI 49202
(517) 789-1292
(517) 789-1271 (fax)
For Genesee or Shiawassee County:
Tinamarie Hubbard
Resource Genesee
605 N Saginaw St, Suite 2
Flint, MI 48502
(810) 232-6411
(810) 232-3738 (fax)
Central Michigan 2-1-1 Revised 10/10/2013
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Central Michigan 2-1-1 Revised 10/10/2013
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