Agency Profile Form

Please use this form to submit agency information, additions or changes to your agency detail.

Description of Agency

Describe your agency including an overview of your programs and services.


Keywords

List keywords that the public may use to find your service.


For Profit
Nonprofit
Government
 

Physical Address

Mailing Address

Contact Information

Hours of Operation

Geographic Area Served

Please include counties, cities, and towns for which your agency/organization provides services.


Intake Procedure

Describe the standard intake procedures required to obtain services.


Intake Requirements

Describe any intake or documentation requirements.


Eligibility

Describe eligibility requirements

Infants Toddlers
Children Adolescents
Adults Seniors
All Ages  
Females
Males
Either
 

Types of Fees
No Cost Low Cost
Sliding Fee Other
Vary Fixed
Donation  

Insurance/Method of Payment
MaineCare
Medicare
Cash
Credit Cards
Private Insurance
Personal Check
 

Personnel

(The director information will not be published.)

Languages Spoken
English
Spanish
French
 

EIN

Any additional information you wuold like us to be aware of?

Please let us know if you would prefer that the information below not be published

Do not publish
 

Questions?

Please contact Pam Levesque at (207) 941-2800 ext. 219. You may also contact Pam through email at paml@unitedwayem.org.

Submission of this form does not guarantee inclusion within the 2-1-1 Maine web-based Resource Directory.

 Thank you!


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