Name *
Email *
Local Resource Category *	Select One Mental Health Providers Supportive Community Services Other
Business / Organization / Agency Name *
Address *
Phone *
Crisis Phone (if appropriate)
Contact Name *
Contact Email *
Website
Brief Description of the Services You Offer:
Therapists’ Names and Areas of Expertise (If Applicable):
Do You Have a Psychiatrist on Staff? If Yes, Their Name(s):
How Can Someone Access Your Services?
Hours of Service:
For Mental Health Providers - Is there a cost:
For Mental Health Providers - Method of payment and insurances accepted:
For Mental Health Providers - Do you accept medical assistance:
Services That You Offer to Clients Whose First Language is Other Than English:
Other Information That Should be Included to Describe Your Organization: