Resource Database Information Sheet Resource Database Information Sheet AGENCY INFORMATION Agency Name * Other Names for Organization (AKA or Acronym) Agency Physical Address * Agency Physical Address Agency Physical Address Agency Physical Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Is this address confidential? * Yes No Is public transportation available to this location? * Yes No Is the agency mailing address the same as the agency physical address? * Yes No Agency Mailing Address * Agency Mailing Address Agency Mailing Address Agency Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Is this address confidential? * Yes No Email (for agency) * Website URL * Do you authorize 211 to publish your address(es) on our public website and in printed materials? * Yes No Comments Agency Overview: Please describe your agency. * Phone Information Phone Type * MainToll-FreeIntakeFaxSpanishTTY/TTDOther Phone Number * plus1 Add Phone minus1 Remove Phone Administrator (Person in charge of agency) Name * Title * Email * Phone * Additional Contact (additional contact information is not released to the public.) Name Title Email Phone Agency Type * Private Non-Profit Faith-Based Non-Profit For-Profit Government Medical Educational Agency Hours of Operation * Has agency been in operation for more than a year? * Yes No Please list date of start-up Site Information Please complete this section for each site as needed. Is the site name the same as the agency name? * Yes No Site Name * Is the site physical address the same as the agency physical address? * Yes No Site Address * Site Address Site Address Site Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Is this address confidential? * Yes No Is public transportation available to this location? * Yes No Is the site mailing address the same as the agency mailing address? * Yes No Site Mailing Address * Site Mailing Address Site Mailing Address Site Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Is this address confidential? * Yes No Site Description: Please list the services/programs offered at this site. Are the site hours the same as agency hours? * Yes No Site hours of operation Are the site phone numbers the same as agency phone numbers? * Yes No Phone 1 Type * MainToll-FreeIntakeFaxSpanishTTY/TTDOther Phone 1 * Phone 2 Type MainToll-FreeIntakeFaxSpanishTTY/TTDOther Phone 2 Accessibility: Please describe any special accessibility considerations. Travel: Please describe any special travel instructions or directions. Is the site coordinator the same contact as the agency administrator? * Yes No Name * Title Email Phone plus1 Add Site minus1 Remove Site Service Information Please complete this section for each of your agency’s services you wish to have listed in the 211 Eastern Oklahoma Resource Database. Service/Program Name * Which site(s) above offer this service? * Service Description * Are the hours of operation for this service the same as the site hours? * Yes No Service Hours of Operation * Intake Procedure * Application required Application preferred Application available online Call about service availability Appointment required Appointment preferred Professional referral required Walk-ins accepted Other information about intake procedureOther information about intake procedure Check all that apply. Fees * None Contact agency for details Set fee Sliding scale Accepts insurance Accepts Medicaid/Soonercare Other information about service feesOther information about service fees Check all that apply. Eligibility * No restrictions Must meet income guidelines Sliding scale Must reside in service area Other information about eligibility requirementsOther information about eligibility requirements Check all that apply. Documents Required * Driver’s License Social Security card Proof of income Proof of address CDIB card Utility bill Other information about required documentsOther information about required documents Check all that apply. Languages, in addition to English * Spanish Russian Hmong Vietnamese Burmese Zomi American Sign Language Call ahead for translator Phone-based translation available Other languages or additional informationOther languages or additional information Check all that apply. Service Area Statewide Service Area Description Please describe counties, cities, or ZIP codes served. plus1 Add Service minus1 Remove Service Contact information for person completing this form Same as agency administrator Use contact information for agency administrator Name * Email * Phone * Date Please note: 211 Eastern Oklahoma provides a free information and referral service to the public. Referrals are made based on the client’s service needs and location. A listing in the 211 Eastern Oklahoma database does not constitute an endorsement by 211 Eastern Oklahoma or its parent organization, Tulsa Area United Way. 211 Eastern Oklahoma reserves the right to edit information for brevity, clarity, and content. Submit If you are human, leave this field blank.
