Agency Listing Application Thank you for your interest in having your agency listed in the 211 Ventura database. If your agency is NOT in the 211 Ventura database, please use this form to submit your agency listing application. Before you start filling out this form, please review the 211 Ventura County Inclusion/Exclusion Policy first. Agency must meet the inclusion criteria listed to be considered. Thank you! If your agency is already listed in the 211 Ventura database, please use the program listing application to submit new program information. Does your organization provide services that are appropriate for inclusion in the 211 database, based on the 211 Santa Barbara County Inclusion/Exclusion policy (linked above)?(Required) Yes No Have you been in operation for at least six months?(Required) Yes No Your Name(Required)Email(Required) Agency Name(Required)Agency Description(Required)Agency Type(Required)Not-for-profit (incorporated)Not-for-profit (not incorporated)Government - FederalGovernment - StateGovernment - CountyGovernment - CityFaith-basedMembershipSpecial DistrictPrivate PracticeFor-profit/CommercialAgency Website Agency General Email (for public use) Physical Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this location wheelchair accessible?(Required) Yes No Is this location confidential?(Required) Yes No Is your Mailing Address the Same as Your Physical Address? Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Administration Office Hours(Required)Agency General Phone Number(Required)TDD/TTY Number (if any)Agency Primary Contact InformationThe best person for 211 to contact with questions about your service or to update the 211 record.Agency Primary Contact Name(Required)Agency Primary Contact Title(Required)Agency Primary Contact Email(Required) Senior Contact Phone NumberAgency Senior Executive InformationOrganization Executive Director/CEO/PresidentSenior Contact NameSenior Contact TitleSenior Contact Email Agency Primary Contact Phone Number(Required)Program InformationProgram Name(Required)Program Description(Required)Program Residency Requirement(Required)No residency requirementMust be a citizen of the United StatesMust be a California residentMust be a Ventura County residentMust be a resident of a specific city-explain through program Eligibility belowMust be a resident of a specific zip code-explain through Eligibility belowProgram Eligibility(Required)Language Offered(Required) English Spanish Other Interpreter Services Available Other languagesProgram Fees(Required) No fee Fees vary based on income Fees vary based on services Sliding scale fee based on income Set program fee Accepts Medi-Cal Accepts Medicare Accepts most insurance Membership fee Fee informationExplain fee range for sliding scale, fees vary, set program fee, membership fee, etc.Program Intake Procedure(Required)Visit during program hoursCall or visitCall for an appointmentCall for intakeCall to applyReferral required-provide additional notes belowOther-provide additional notes belowAdditional notes on Intake ProcedureDocument(s) Required at Intake(Required)Program Website Program Hours(Required)Program Phone Number 1 and phone description(Required)Program Phone Number 2 and phone description (if any)Program Phone Number 3 and phone description (if any)TDD/TTY NumberProgram Physical Address 1 where service is offered(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is program location 1 wheelchair accessible? Yes No Is program location 1 confidential? Yes No Program Physical Address 2 where service is offered Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is program location 2 wheelchair accessible? Yes No Is program location 2 confidential? Yes No Program Physical Address 3 where service is offered Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is program location 3 wheelchair accessible? Yes No Is program location 3 confidential? Yes No Is your Program Mailing Address the Same as Your Program Physical Address? Yes No Program Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional InformationCAPTCHA
