Service Information Form

    Please complete the following to provide us with information about your services. Please complete a separate form for each service you offer.

    If you haven't completed an Agency Information form yet, please click here to submit information about your agency.

    If you have any questions, please feel free to contact Laurie at (714) 589-2364, or e-mail This email address is being protected from spambots. You need JavaScript enabled to view it. 

    1. Agency Name (Legal name of the agency)(*)
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    2. Service Name(*)
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    3. Other names this service may be known by (Former names, acronyms, etc.)
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    4. Service Description (Please provide a brief description of the service offered and the target population it is intended for)(*)
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    5. Physical Address of Primary Service Location
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    6. City
      Please enter a valid City name.
    7. ZIP Code
      Please enter a valid ZIP code.
    8. Is this address confidential?
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    9. Is this location disabilities accessible?
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    10. Please describe any accessibility in the building that either helps or hinders people with disabilities
      (e.g. Wheelchair accessibility, Wheelchair ramps, No elevator to the second floor, etc.).
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    11. Mailing Address
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    12. Mailing Address
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    13. City
      Please enter a valid city name.
    14. Zip Code
      Please enter a valid ZIP code.
    15. Is this service offered at multiple locations?
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    16. Physical Address of Location 2
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    17. City of Location 2
      Please enter a valid City name.
    18. ZIP Code of Location 2
      Please enter a valid ZIP code.
    19. Is the address of this location confidential?
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    20. Is this location disabilities accessible?
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    21. Please describe any accessibility in the building that either helps or hinders people with disabilities
      (e.g. Wheelchair accessibility, Wheelchair ramps, No elevator to the second floor, etc.).
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    22. Is this service offered at another location?
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    23. Physical Address of Location 3
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    24. City of Location 3
      Please enter a valid City name.
    25. ZIP Code of Location 3
      Please enter a valid ZIP code.
    26. Is the address of this location confidential?
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    27. Is this location disabilities accessible?
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    28. Please describe any accessibility in the building that either helps or hinders people with disabilities
      (e.g. Wheelchair accessibility, Wheelchair ramps, No elevator to the second floor, etc.).
      Invalid Input
    29. Is this service offered at another location?
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    30. 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. :)
    31. Referral Phone (For clients to inquire about service)
      Please enter a valid 10-digit phone number.
    32. Program/Service Website (If service is provided online)
      Please enter a valid URL (e.g. https://www.example.com)
    33. Is a screening or assessment meeting required before clients receive service?(*)
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    34. Intake Hours (If screening or assessment is required, Days and Times screening/assessment meetings are available)(*)
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    35. Service Hours (Days and Times service is provided)(*)
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    36. Ages Served(*)
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    37. Eligibility
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    38. Additional Eligibility Information (please select any of the following applicable to this service)
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    39. Languages the entire service is provided in(*)
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    40. Other language(s)
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    41. Payment Options(*)










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    42. Service Fee Amount (please specify fee amount or sliding-scale range)
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    43. Application Process (How do clients initially access this service?)(*)





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    44. Please specify other application processes(*)
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    45. This service is provided...(*)



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    46. Documentation required upon intake(*)

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    47. Please select the documentation required for this service(*)




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    48. Other documentation required
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    49. Will you provide service to unaccompanied minors?
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    50. Genders Served(*)




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    51. Areas Served(*)


      Please select one.
    52. Specific Locations (please specify the cities, zip codes or other areas served)(*)
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    53. Is there any additional information you would like us to know about this program?
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    54. Your Name(*)
      Please enter your name.
    55. Title(*)
      Please enter your title.
    56. Your Phone(*)
      Please enter a valid 10-digit phone number.
    57. Your E-mail(*)
      Please enter a valid email address (e.g. email@example.com).
    58. Are you the Program Administrator for this service? (Person 211OC Staff can contact to verify service information)(*)
      Please select one.
    59. Program Administrator Contact (Person 211OC Staff can contact to verify service information)
    60. Name(*)
      Please enter the name of the program administrator.
    61. Title(*)
      Please enter the title of the program administrator.
    62. Phone(*)
      Please enter a valid 10-digit phone number.
    63. E-mail(*)
      Please enter a valid email address (e.g. email@example.com).
    64. Please Enter Code(*)
      Please Enter Code
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    Thank you! Please allow 2-3 business days for a Resource Specialist to respond.


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