Service Information Form

Please complete the following to provide us with information about your services. Please complete a separate form for each service you offer.

If you haven't completed an Agency Information form yet, please click here to submit information about your agency.

If you have any questions, please e-mail resource@unitedwayoc.org

Agency Name
(Legal name of the agency) *

Are you a current GetHelpOC partner and would you like to list this service for Direct Referrals? Or are you interested in learning more about becoming a closed loop referral partner? *

Yes

No

Don't know

Service Name
(This should be different from the agency name and be specific to a program or service) *

Other names this service may be known by
(Former names, acronyms, etc.)

Service Description
(Please provide a brief description of the service offered and the target population it is intended for) *

Physical Address of Primary Service Location *

Select One... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territory Nova Scotia Nunavut Territory Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Is this address confidential?

Yes

No

Please select the type of disabilities access this location has

Fully accessible to individuals using mobility aids

Potential limitations to access in some service areas – call for details

Designated, accessible parking spaces

Service area is not accessible

Mailing address same as physical address

Mailing Address *

Select One... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territory Nova Scotia Nunavut Territory Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Is this service offered at multiple locations?

Yes

No

Referral Phone

Program/Service Website

Service Hours
(Days and Times service is provided) *

Ages Served *

Eligibility *

Additional Eligibility Information
(please select any of the following applicable to this service)

Income required

Employability required

Employment required

Disconnection notice required

Eviction notice required

Serves Anaheim Public Utilities customers

Serves Edison customers

Serves SDG&E customers

Serves The Gas Company customers

Languages the entire service is provided in

English

Spanish

Vietnamese

Farsi/Persian

Korean

Mandarin

Cantonese

American Sign Language

Interpreter Service/Language Line Available

Other (please specify)

Payment Options

No fee

Fees vary

Set program fee or Sliding Scale

Accepts Medi-Cal

Accepts Medicare

Accepts most insurance

Scholarships available

Donation requested

Membership fee

Call for fee information

Service Fee Amount
(please specify fee amount or sliding-scale range)*

Fee Information
(Please detail any additional fee information)

Application Process
(How do clients initially access this service?)

Walk-ins accepted

Appointments accepted

Appointments required

The phone line is not staffed client must leave a voicemail

Call for detailed information

Other (please specify)

Please describe the expectations for first contact
(When can the applicant expect to be contacted? Please include any details that would be helpful to know when applying)

This service is provided...

In-person

Via telephone

Online

In-home

Documentation required upon intake *

None required

Specific documents required (please select)

Please select the documentation required for this service

Proof of residence within coverage area

Birth certificate

Government-issued picture ID

Social Security Card

Other (please specify)

Will you provide service to unaccompanied minors? *

Yes

No

Does this program serve people without legal US residency?
(For internal use only. This information is kept strictly confidential)

Yes

No

Genders Served

Women

Men

Trans

Trans Women/MTF

Trans Men/FTM

Areas Served

Serves anyone, no geographic restrictions

Serves all Orange County residents

Other geographic restrictions (i.e. cities or zip codes)

Specific Locations
(please specify the cities, zip codes or other areas served)

Is there any additional information you would like us to know about this program?

First Name *

Last Name *

job Title *

Are you the Program Administrator for this service?
(Person 211OC Staff can contact to verify service information)

Yes

No

Your Phone *

Your E-mail *

I'm not a robot *

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