Agency Name

Please include the full, official name of your agency. Also list any other names by which your agency may be know. For example, the University of Memphis is also known as MSU or Memphis State University.

Address

Enter the agency's address, including zip code. Also, please enter any branches or alternate addresses for your agency.

Phone Number:

If the agency has more than one phone number, please indicate which one is the primary number. Is there an answering machine/service? Indicate if phone hours differ from regular business hours. If you would prefer that your fax number or e-mail address not be shared on a public database, please indicate this.

Director:

Please show the agency's director, etc., along with his/her title.

Contact Person:

Please list person to contact for each service, or the directors of specific programs or services within the agency.

Hours:

Include daily hours of operation (e.g., 8-4, M-F). Indicate if appointments are required for service. If hours vary, please make an appropriate statement, such as "None specified, residence phone."

Date:

Show the date you are submitting this information.

Services:

Please list each service on separate form, with enough detail that appropriate referrals can be made. Please do not put on the same form services with differing eligibility requirements. If you submit more than one form at the same time, you do not need to repeat information, other than organization name, which is the same for all services. You do not need to make a separate form for generic services such as speakers bureaus, field trips, and pamphlets, but please include them.

Eligibility:

Please indicate eligibility criteria (e.g., age, residency, income) for each service.

Fees:

These are the charges and costs to be expected for service(s). Please indicate if service fees are based on ability to pay. Also, specify if insurance and other third party payments are accepted and if any membership fees are required for services. Accepted TennCare plans should be listed here.

Application:

What processes (e.g., pre-screening by another agency, income verification, documents needed, doctor's referral) must be completed in order to receive services? Please indicate if there is a waiting list.

Funded By:

List agency funding sources (e.g., United Way of Greater Memphis, grants, contributions, memberships, TN Dept. of Human Services.)

Handicapped Accessible:

Are facilities accessible to the handicapped? Indicate any limitations.

Non-English Services:

If services are available in a language other than English (including American Sign Language), please indicate.

Bus Stop:

Please indicate nearest bus line, if any, to agency, and where the bus stops.

Division of Government:

For government agencies only. Indicate which governing body(ies) your agency falls under. For example, Health Dept. (Memphis/Shelby Co.) - Memphis and Shelby County would both be checked.

City of Memphis

Shelby County

State of Tennessee

U.S. Government

Comments:

Please include any information that will help to explain further your agency's service, including agency publications. Also, please list the name of the person submitting this information, and his/her phone number if different from the agency's general number.

Please review what you have entered above and then submit the form.