2-1-1 OrangeCounty

Program Profile

Please complete this Program Profile for each program you offer. Make additional copies as needed.

  1. Agency name:
  1. Program Name: (If your service is not divided into programs leave blank):

Is this program seasonal? Yes No

If yes, then indicate time frame:

  1. AKA Names:Please provide any names the above program may also be known as in the community (former names, acronyms, etc):
  1. Program Site Address: (Where program/service is delivered):

Is this address confidential? Yes No

Is this address handicap accessible? Yes No

Is your facility located within 3 or 4 blocks of public transportation?Yes NoBus Route

Major cross street(s):

  1. Program Phone Numbers: Please list and identify any phone numbers used specifically for this program/service:

Phone / Type (i.e. Intake, Admin, TTY, Etc.)
()
()
()
  1. Program Email/Website Information:

Email: Website:

  1. Program Description:Please describe the specific services provided and the population it serves. Please distinguish between primary and secondary services (only available to clients participating in other services i.e. “childcare for people taking English as a Second Language class”). This information may or may not be published in directories, so please be as comprehensive, yet as brief as possible. Please be cautious of abbreviations and acronyms. (Note: 2-1-1 OrangeCounty reserves the right to edit as necessary for space consideration and consistency.)
  1. Keyword Service Terms: HMG Staff—Please list any keywords or services terms that would be helpful in identifying this program during Service term searches.
  1. Hours: Please identify hours that relate only to this program/service:

Program Hours
Monday / to
Tuesday / to
Wednesday / to
Thursday / to
Friday / to
Saturday / to
Sunday / to
  1. Volunteers: Does your agency use volunteers? Yes No

If yes, what jobs do they perform?

11.Areas Served: Please describe service area:

Servesall regions of OrangeCounty, with no geographic restrictions

Limited to the following areas. Please check cities listed below or describearea designations.

Area designation description (i.e. Parish Boundaries, Zip Codes, Etc.):

Aliso Viejo / La Palma / San Juan Capistrano
Anaheim / Laguna Beach / Santa Ana
Brea / Laguna Hills / Seal Beach
Buena Park / Laguna Niguel / Stanton
Costa Mesa / Laguna Woods / Tustin
Cypress / Lake Forest / Villa Park
DanaPoint / Los Alamitos / Westminister
Fountain Valley / Mission Viejo / Yorba Linda
Fullerton / Newport Beach
Garden Grove / Orange
Huntington Beach / Placentia / Unincorporated
Irvine / Rancho Santa Margarita / California
__ / La Habra / San Clemente / National
  1. Eligibility: Please check all that apply and add information as requested.

Not limited

Age

Youngest Served: years Oldest Served: years

Gender

Males only Females only Transgendered Male Transgendered Females

Family Composition

Single CouplesFamilies with Children Pregnant

Ethnic Requirement

Describe:

Income StatusEmployment Required

Serve undocumented immigrants

Serve felonsSobriety Required

Referrals from other agencies or professionals required

Describe:

Other: please indicate any other criteria required for participation in or access toprograms/services

Explain:

  1. Documentation Requirements: Please check all that apply.

None RequiredPicture IDSocial Security Card

Proof of Residence,Proof of InsuranceBirth Certificate

Rent, Utility Bill

Medical or Psych RecordsDrivers LicenseVary, Instruct to Ask

Other:

  1. Languages:Please list the languages (including English) that are routinely available and spoken by staff and/or volunteers providing services:

Language Line or Interpreter Services Available?Yes No

  1. Intake Procedure: What procedure does your agency use for intake? Please check all that apply:

TelephoneWalk inAppointment Required

No Walk insSelf Referral

Referral Required. By Whom?

Other:

16.Fees: Please check the option that applies to your agency and provide the amount or the upper and lower range in the spaces provided (please do not leave any blanks)

No FeesProgram Fees

Ability to pay/sliding scale from $ to $

Membership: Amount $

Donation requested for service: Suggested amount $

Other:

  1. Insurance: Check all that apply:

Medi-Cal (Cal-Optima)Private InsuranceHealthy Families

Military InsuranceDenti-CalMSI

MedicareNo Insurance AcceptedUninsured

Other:

  1. Disabilities Served: If your program serves any specific disabilities, please state below:
  1. Donations: Please select and describe:

Donations Accepted Donation Pick Up Available No Donations Accepted

Completed by: Deanna Parga Date:

Title:Community LiaisonPhone:714.939.7141

Please mail or fax completed form to:

Help Me Grow--OrangeCounty

1915 W. Orangewood Avenue, Suite 303

Orange, CA92868

Phone #: 714-939-7122 Fax #: 714-939-6199

10/5/20181