Agency Name (Legal name of the agency)(*)
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Service Name (*)
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Other names this service may be known by (Former names, acronyms, etc.)
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Service Description (Please provide a brief description of the service offered and the target population it is intended for)(*)
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Physical Address of Primary Service Location
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City
Please enter a valid City name.
ZIP Code
Please enter a valid ZIP code.
Is this address confidential?
No Yes Invalid Input
Is this location disabilities accessible?
No Yes Invalid Input
Please describe any accessibility in the building that either helps or hinders people with disabilities
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Mailing Address
Same as Physical Address Invalid Input
Mailing Address
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City
Please enter a valid city name.
Zip Code
Please enter a valid ZIP code.
Is this service offered at multiple locations?
No Yes Invalid Input
Physical Address of Location 2
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City of Location 2
Please enter a valid City name.
ZIP Code of Location 2
Please enter a valid ZIP code.
Is the address of this location confidential?
No Yes Invalid Input
Is this location disabilities accessible?
No Yes Invalid Input
Please describe any accessibility in the building that either helps or hinders people with disabilities
Invalid Input
Is this service offered at another location?
No Yes Invalid Input
Physical Address of Location 3
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City of Location 3
Please enter a valid City name.
ZIP Code of Location 3
Please enter a valid ZIP code.
Is the address of this location confidential?
No Yes Invalid Input
Is this location disabilities accessible?
No Yes Invalid Input
Please describe any accessibility in the building that either helps or hinders people with disabilities
Invalid Input
Is this service offered at another location?
No Yes Invalid Input
Wow! That's a lot of sites! Go ahead and just continue filling out this form, submit it as-is, and a Resource Specialist will contact you to gather the rest of the information about all of the service locations. :)
Referral Phone (For clients to inquire about service)
Please enter a valid 10-digit phone number.
Program/Service Website (If service is provided online)
Please enter a valid URL (e.g. https://www.example.com)
Is a screening or assessment meeting required before clients receive service? (*)
No Yes Invalid Input
Intake Hours (If screening or assessment is required, Days and Times screening/assessment meetings are available)(*)
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Service Hours (Days and Times service is provided)(*)
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Ages Served (*)
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Eligibility
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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 Invalid Input
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) Invalid Input
Other language(s)
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Payment Options (*)
No fee Fees vary Set program fee Sliding scale Accepts Medi-Cal Accepts Medicare Accepts most insurance Scholarships available Donation requested Membership fee Call for fee information Invalid Input
Service Fee Amount (please specify fee amount or sliding-scale range)
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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) Invalid Input
Please specify other application processes (*)
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This service is provided... (*)
In-person Via telephone Online In-home Invalid Input
Documentation required upon intake (*)
None required Specific documents required (please select) Invalid Input
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) Invalid Input
Other documentation required
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Will you provide service to unaccompanied minors?
No Yes Invalid Input
Does this program serve people without legal US residency? (For internal use only. This information is kept strictly confidential)
No Yes Invalid Input
Genders Served (*)
Women Men Trans Trans Women/MTF Trans Men/FTM Invalid Input
Areas Served (*)
Serves anyone, no geographic restrictions Serves all Orange County residents Other geographic restrictions (i.e. cities or zip codes) Please select one.
Specific Locations (please specify the cities, zip codes or other areas served)(*)
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Is there any additional information you would like us to know about this program?
Invalid Input
Your Name (*)
Please enter your name.
Title (*)
Please enter your title.
Your Phone (*)
Please enter a valid 10-digit phone number.
Your E-mail (*)
Please enter a valid email address (e.g. email@example.com).
Are you the Program Administrator for this service? (Person 211OC Staff can contact to verify service information)(*)
No Yes Please select one.
Program Administrator Contact (Person 211OC Staff can contact to verify service information)
Name (*)
Please enter the name of the program administrator.
Title (*)
Please enter the title of the program administrator.
Phone (*)
Please enter a valid 10-digit phone number.
E-mail (*)
Please enter a valid email address (e.g. email@example.com).
Please Enter Code(*)
