Western Colorado 2-1-1

Western Colorado 2-1-1

2-1-1 is a free, confidential, information and referral service connecting people
in need to important local community resources via the phone, web or app.

2-1-1 can pre-screento ensure that agencies are using their resources wisely; we refer only those who meet your agencies/services eligibility guidelines

2-1-1 can save time. 2-1-1 is a resource for your staff. We are a free time-saving tool for social workers, doctor, nurses, and government officials and more.

2-1-1 can field the first call. 2-1-1 serves as the first point of contact to other organizations and can alleviate administrative burden and reduce cost associated with managing information and referrals allowing organizations to focus on serving clients, rather than finding clients.

2-1-1 can promote programsto target audiences to increase outreach and program participation.

Please complete an application for each site of the program/service your agency provides. It allows for 2-1-1 to give accurate information and referrals to clients seeking help. If you have any questions related to the application below or to the process of listing your agency or program/service in the Western Colorado 2-1-1 database, please contact our office by dialing 211 or our toll free number 1-888-217-1215.

Inclusion / Exclusion Criteria

Have you read the inclusion policy? * Choose an item.

Have you been in operation for at least one year? *Choose an item.

What type of services do you offer? * Choose an item.

If “other” please explain:Click here to enter text.

Agency Name * (legal name):Click here to enter text.

Description of Agency *:Click here to enter text.

Aliases * (other names or acronyms the agency is known by): Click here to enter text.

Agency Type: Choose an item.

If other, please explain: Click here to enter text.

Employer Identification Number:Click here to enter text.

Physical address: (if you do not have a physical address, please enter NA)
Physical Site Address 1: Click here to enter text.
Physical Site Address 2: Click here to enter text.
Physical Site City: Click here to enter text.
Physical Site State:Click here to enter text.
Physical Site Zip: Click here to enter text.
Is the Physical location confidential? *Choose an item.

Mailing Address:(if mailings address same as physical then leave blank)
Mailing Address 1: Click here to enter text.
Mailing Address 2: Click here to enter text.
Mailing City: Click here to enter text.
Mailing State: Click here to enter text.
MailingZip: Click here to enter text.

Agency Contact Information
Main Phone # (include extension if applicable): Click here to enter text.
Phone Type:Choose an item.
If other, please explain:Click here to enter text.
Fax #: Click here to enter text.
Email *: Click here to enter text.
Web Address*: Click here to enter text.
TDD Phone: Click here to enter text.
Hotline Phone: Click here to enter text.
Emergency/After Hours Phone: Click here to enter text.
Other Phone: Click here to enter text.

Agency/Administration Hours*: Click here to enter text.

Director Information:
Director Title: Click here to enter text.
Director’s Name: Click here to enter text.
Director’s Phone #: Click here to enter text.
Director’s Email: Click here to enter text.
Do you want the director information hidden from public view? Choose an item.

Primary Agency Contact for Updates to Programs and Services
Requests to update your agency will be sent to this email address.
Contact Name: Click here to enter text.
Contact Title: Click here to enter text.
Contact Email *:Click here to enter text.
Contact Phone #: Click here to enter text.

PROGRAM/SERVICE INFORMATION:
Affiliated Agency Name *: Click here to enter text.
Program/Service Name *: Click here to enter text.
Aliases (aka, other names or acronyms the agency is known by):Click here to enter text.
Description of Primary Services*:Click here to enter text.
A program description is a short detailed summary of the organization’s prime nature and activities. Use search terms such as food, housing, and additional information about your services that would be helpful for clients and for 211 Call Navigators to identify appropriate referrals.

Secondary Services: Click here to enter text.
These are services clients can receive once enrolled in primary services. For example, if a client is enrolled in job searching / computer training he/she may be able to receive additional ongoing assistance such as child care while participating in program service job searching/computer training.

Please list the keywords describing this program/service that will be searchable in the 211 database.
Click here to enter text.

Geographical Information:(area served)

How many physical locations offer this program/service?*: Click here to enter text.
If multiple locations please list physical address and contact number.Click here to enter text.
Geographical area served (i.e. zip codes, cities, counties, communities, etc.):Click here to enter text.
What public transportation is available? (if none, complete as “none”):Click here to enter text.
Facility/ADA Access *: Choose an item.

Intake Procedure
Intake Procedure * (please mark all that apply):
Appointment preferred ☐ Appointment required ☐ Walk in for same day service ☐ Telephone to apply ☐ Walk-in to apply ☐ Agency Referral required ☐
Apply online ☐ Website: Click here to enter text. Not applicable ☐
Intake Requirements *(documents clients need to bring in order to facilitate the intake process. For example: Completed Application, Valid Picture ID, Social Security Card, Birth Certificates, Proof of Income, etc.)
Click here to enter text.

Eligibility Requirements *( income guidelines, age, gender, location, etc.):
Click here to enter text.

Gender Served *:Choose an item.

Fee Information
Types of Fees *: Choose an item.
Other: Click here to enter text.
Fee amounts: Click here to enter text.
Insurance Accepted? *: Choose an item.
Insurance Notes: Click here to enter text.
Payment Notes (cash, check, credit/debit card, etc.): Click here to enter text.

Languages spoken(other than English): Click here to enter text.

Physical Address(if you do not have a physical address, please enter N/A)
Physical Site Address 1:Click here to enter text.
Physical Site Address 2: Click here to enter text.
Physical Site City: Click here to enter text.
Physical Site State:Click here to enter text.
Physical Site Zip*: Click here to enter text.
Is the physical address of the site confidential? *: Choose an item.

Mailing Address(if same as physical than leave blank)
Mailing Address 1: Click here to enter text.
Mailing Address 2: Click here to enter text.
Mailing City: Click here to enter text.
Mailing State: Click here to enter text.
Mailing Zip: Click here to enter text.

Agency Contact Information
Main Service Phone # (include extension if applicable): Click here to enter text.
Phone Type:Choose an item.
If other, please explain:Click here to enter text.
Fax #: Click here to enter text.
Service location email: Click here to enter text.
Web Address: Click here to enter text.
TDD Phone: Click here to enter text.
Hotline Phone: Click here to enter text.
Emergency Phone: Click here to enter text.
Other Phone: Click here to enter text.

Hours of Operation
Intake Hours of Operation: Click here to enter text.
Specific Hours (if different from intake) : Click here to enter text.

Update Cycle
How often do you update your program? *:Choose an item.

Contact Info for update requests
Contact Name:Click here to enter text.
Contact Title:Click here to enter text.
Contact Email:Click here to enter text.
Contact Phone #:Click here to enter text.

Signature

BY ENTERING MY INFORMATION BELOW, I VERIFY THAT ALL OF THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IN ORDER TO KEEP WESTERN COLORADO 2-1-1 DATABASE ACCURATE AND UP TO DATE, I AM REQUIRED TO INFORM WESTERN COLORADO 2-1-1 OF CHANGES TO THE AGENCY’S OPERATIONS WITHIN 30 DAYS.

I UNDERSTAND THAT WESTERN COLORADO 2-1-1 CONDUCTS AN ANNUAL SURVEY TO VERIFY CURRENT INFORMATION AND THAT IN ORDER TO REMAIN WITHIN THE DATABASE I MUST COMPLY WITH UPDATING THE INFORMATION UPON REQUEST. DURING THIS TIME AN ELECTRONIC EMAIL () MESSAGE WILL BE SENT FAILURE TO COMPLY WITH THESE REQUIREMENTS MAY RESULT IN THE DEACTIVATION OF MY AGENCY ORAGENCIES SERVICES WITHIN THE 2-1-1 DATABASE.

I HAVE READ AND UNDERSTOOD WESTERN COLORADO 2-1-1 INCLUSION/EXCLUSION POLICY LINKED TO ON THIS WEBPAGE AND WILL SUBMIT ALL FORMS OF PROOF OF LICENSURE AS REQUIRED BY REGULATING AGENCIES. I ALSO AM AWARE THAT APPLICATIONS WILL BE PROCESSED WITHIN 30 DAYS.

Your full name*: Click here to enter text.
Title: Click here to enter text.
Phone #: Click here to enter text.
Email: Click here to enter text.