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Charles County Community Resource Survey
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1.
Name of Agency / Organization
(Required.)
2.
Sub-division within Agency (skip if not applicable)
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3.
Service(s) Provided
(Required.)
Housing
Food
Clothing
Mental Health
Extracurricular / Recreational
Education
Youth
Adult
Senior
Family Support
Prenatal/Expectant Parents
Physical Health
After Hours / Emergency
Disability
Substance Use
Victim Services
Employment
Financial Assistance
Other (please specify)
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4.
What ages do you serve?
(Required.)
0-5
6-12
13-17
18-59
60+
Other (please specify)
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5.
What insurance is required for your services?
(Required.)
Medical Assistance / Medicaid
Some Private Insurance
None
Fee for Service
Other (please specify)
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6.
Is there a limited number of times/ sessions a person can receive services?
(Required.)
No
If yes, (please specify)
7.
Are your services available multilingually?
Yes
No
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8.
Please provide a brief description of your services and what they do
(Required.)
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9.
Is there a waitlist?
(Required.)
Yes
No
Sometimes
If yes, how long is the average waitlist?
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10.
Do you have "after hours" services?
(Required.)
Yes
No
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11.
Is a referral needed?
(Required.)
Referral needed
Self referral
No referral needed
If yes, from whom?
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12.
Agency Contact Information
(Required.)
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
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13.
Please list links of your online content
(Required.)
14.
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