CONTACT INFO:

Address:     City:        State:        Zip Code:

Phone:        Fax:     

Web Address:          E-mail:

HOURS/DAYS:

Hours: to     Days:

DESCRIPTION: Explain the services and programs your agency provides.  Please be as specific as possible.

ELIGIBILITY:  (Are your services limited based on age, gender, income, etc?)

LANGUAGES: What languages are available and spoken by your staff?

English                             American Sign Language

Spanish                            Other

FEES: What is your fee structure?

    No Fee           

    Sliding Scale

    Straight Fee - No Adjustments

    Other Considerations

INSURANCE: Does your agency accept any insurance or third party coverage?

    N/A

    Yes

   PeachCare

   Medicaid

  Medicare

LISTING INFORMATION:

All agency information provided to us will be listed both alphabetically and categorically.  To assist us in making sure your agency is listed in all of the applicable categories, please identify the areas that correspond to your agency.

Family Resources                            Hispanic Resources                            Utilities

Special Needs Resources                Senior Resources                               City & County Government

Youth Resources                             Donation Sites                                   Elected Officials

Holiday Donation Needs                 Employment Services                         Education

Clothing Banks                                Food Banks                                      Civic Organizations

Dental Care                                    Health Care                                        Faith Community

Housing                                          Transportation Services                      Health Related Organizations

Local Media                                   Counseling Services                            Domestic Violence Resources

Drug & Alcohol                              Legal Services                                    Recreation

Arts & Entertainment

FOR FOCUS USE ONLY:

In case we need to contact you for more information or clarification, please provide contact information.  This information is confidential and will not be included in the website.

Contact Name:

             Phone:

              E-mail:

* Please be advised that submission of information does not guarantee it will be included on this website. *