Agencies | Online Services | Policies

ARIC Service Provider Survey (last updated, 10/26/98)

Organization/Program Name:

Contact Title/Person:

Address:

Street

PO Box

City                                                   /    State                                         /  Zip

County in which you are located:

Phone Numbers: Please add area code & use the format: (xxx) xxx-xxxx

FAX: Please add area code & use the format: (xxx) xxx-xxxx

Home Page: Please use format: http://www.www.www/

E-Mail:

Counties Served (list all that apply):

Days of Operation:

1. 7 days
2. M-F
3. M-Sat
4. other

 Hours of Operation:

1. 24 hours
2. 7:00am-7:00pm
3. 7:45am-3:15pm
4. 8:00am-4:00pm
5. 8:00am-4:30pm
6. 8:00am-5:00pm
7. 9:00am-4:00pm
8. 9:00am-5:00pm
9. other
Cost of Program:

1. NONE
2. fee-based
3. other
4. sliding-scale based on income

 Status:

1. 501(c)3
2. Educational
3. For Profit
4. Government
5. Other
Demographics of persons served:

1. 18 and over
2. 21 and over
3. 55+
4. 60+
5. 65+
6. All
7. Boys only
8. Girls only
9. Other - see description at bottom
10. Parents/guardians
11. adults with disabilities 18+
12. adults with disabilities 21+
13. adults with disabilities 21-64
14. children with disabilities
15. families of adults with disabilities
16. families of senior adults
17. under 18
18. under 21

 Financial eligibility requirements:

1. 100% poverty
2. 125% poverty
3. 130% poverty
4. 135% poverty
5. 200% SSI
6. 200% poverty
7. 300% SSI
8. Medicaid Eligible
9. NONE
10. Other - see details below
11. SSD
12. SSI
13. asset amount
14. monthly income amount
Mobility requirements:

1. Ambulatory only
2. NONE
3. assistance with 2 or more ADLs (Activities of Daily Living)
4. homebound
5. other
6. supervision required
7. wheelchair only

  

 

 

 

 

 

 

 

Services/Codes: (circle all that apply)
- New categories are added weekly, so some will not have numbers beside them. Don't worry about that!

1. ADHD/ADD
2. AIDS/HIV
3. Adolescent Treatment Facility
4. Adult Day Care
5. Advocacy
6. Aging
7. Alzheimer's
8. Animal Services
9. Area Agency on Aging
10. Arkansas' Promise Promise-Maker
11. Arthritis
12. Cancer - education
13. Cancer - screening / prevention
14. Cancer - support
15. Cancer - treatment
16. Case Management
17. Child Abuse Prevention / Treatment
18. Child Care / Day Care
19. Church
20. Clothing
21. Coalition Building
22. Community Development
23. Community Health Education
24. Consumer Services
25. Court
26. Crime prevention
27. Disability Services
28. Disaster
29. Displaced workers
30. ESL
31. Education
32. Elder Abuse Prevention / Treatment
33. Emergency Assistance
34. Employment Services
35. Family planning
36. Financial Assistance
37. Financial Counseling
38. Food
39. Foreign Language
40. Fundraising
41. GED Assistance
42. Grants / Funding Source
43. Grantwriting Assistance
44. Grief / Grieving
45. Home Health Care
46. Hospice
47. Hospital
48. Housing (not temporary shelter)
49. Independent Living Skills Training
50. Information and Referral
51. Inservice Training
52. Legal Services
53. Library
54. Media (newspaper, radio, etc.)
55. Medical Supply
56. Mentoring
57. Military/ Veterans Services
58. Multiple Sclerosis
59. Need donations - cash
60. Need donations - clothing

 61. Need donations - food
62. Need donations - other
63. Neglect - elder
64. Neighborhood Association
65. Nutrition/Meal Services
66. Parenting
67. Peer support and counseling
68. Philanthropic Organization (provides funding / gifts )
69. Physical Health / Medical Conditions
70. Political Organization
71. Pregnancy (education, counseling, etc.)
72. Prescriptions - cash assistance
73. Prescriptions - home delivery
74. Prevention - alcohol, tobacoo, other drugs
75. Psychological Counseling / Mental Health
76. Public Speaking - informational
77. Recreation
78. Rehabilitation
79. Religious / Spiritual Needs
80. Relocation services
81. Rent assistance
82. Residential Care Facilities (nursing homes, etc.)
83. Scholarships
84. School, College/University
85. School, K-12
86. School, Parochial
87. School, Vocational
88. Senior Center
89. Senior Companions - Foster Grandparents
90. Senior Volunteers - RSVP
91. Senior Volunteers - Senior Companions
92. Seniors - congregate meals
93. Seniors - home delivered meals
94. Seniors - meals on wheels
95. Seniors - socialization
96. Seniors - transportation
97. Sexual Orientation
98. Shelter/Housing (Temporary )
99. Spanish Language Available
100. Spanish Language Translation
101. Special Education
102. Spouse Abuse Prevention / Treatment
103. State of AR Agency / Board / Commission
104. Substance Abuse Services
105. Suicide/Crisis
106. Support Groups
         TEA Coalition Member
107. Teen pregnancy prevention
108. Transportation - General
109. Transportation - Medicaid
110. Transportation - Medical (non-Medicaid)
111. Tutoring - adult
112. Tutoring - k-12
113. United Way Agency
114. Utilities assistance
115. Victim's Services
116. Volunteerism / Placement
117. Volunteers Needed!
118. Wheelchair Accessible
119. Women's Shelter
120. Workforce Education
121. Youth Program