Formal Name of Agency / Provider ______________________________________________________

Street Address of Agency / Provider ___________________________________________________

Directions (attached ____yes _____ no)

Telephone Number - Fax Number - Web Site of Agency / Provider____________________________________
                                                                                                              Telephone            Fax            Web Site

Desired Contact Name (if any) ___________________________________________________________________

Mission Statement of Agency / Provider: (attached as separate document ______ yes ______no)

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Description of Services Available from Agency / Provider ______________________________________________

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Description of Population Served by Agency / Provider ________________________________________________

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Geographic Regions Served by Agency / Provider (circle names of municipalities served)
All of Coos County - Berlin - Carroll/Twin Mountain - Clarksville - Colebrook - Columbia - Dalton - Dixville - Errol - Gorham - Groveton/Northumberland - Jefferson - Lancaster - Millsfield - Milan - Pittsburg - Randolph - Shelburne - Stark - Stewartstown - Stratford - Whitefield - Unincorporated Towns

Description of Fee Structure of Agency / Provider ____________________________________________________

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Insurance Accepted / Insurance Information Required ________________________________________________

Sliding Scale Fees Available _______ yes ________ no

Pro Bono Services Available _______ yes ________ no

Narrative Statement for Web Guide of Agency / Provider: (attached as separate document _____ yes _____no)

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Please list us in the following Service Headings (circle all relevant headings)

Addictions - Assistance Programs - Childbirth - Children Support Groups - Civic Groups - Counseling - Crisis Assistance - Day Care (child & adult) - Disability Resources - Disaster Recovery - Education - Employment - Family Support Groups - Finances - Food - General Information - Health - Homeless/At Risk - Hospice Services - Housing Assistance - Law Enforcement - Legal Services - Mental Health - Military - Political - Pregnancy - Recreation Groups - Senior Citizens - Transportation - Veterans - Volunteer Opportunities - Women

Additional Service Headings Desired by Agency / Provider ___________________________________________

Name/Contact information for Staff Member completing Questionnaire__________________________________

Date Questionnaire Last Modified____________________