Program Information Form

Please use separate forms for each program or service that you provide.

HeartLine information and referral is a free service to the public. Referrals are made based on the client’s service needs and location. A listing in the HeartLine database does not constitute an endorsement by HeartLine. HeartLine reserves the right to edit information for brevity, clarity and content; and to publish the information in a variety of media, subject to confidentiality issues.

Please Note

If you are running out of funds, temporarily discontinuing your service, or have any other corrections to the information in our database, please contact the resource database department immediately. Inclusion in the HeartLine database indicates your willingness to provide us with updated agency/program information by request and as needed. Referrals made with accurate and complete information will help our callers, as well as your agency in the reduction of unnecessary inquiries.

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Program Name

Address

Website

Program Description Please provide a brief description of your program or service.

Special Services Please list any special services you provide for people with disabilities, or seasonal programs and holiday assistance.

Program Hours Please list the days and hours of operation for the program or service.

Service Area Please list the geographic coverage of your program (statewide, county, city, zip, etc.)

Program Eligibility Please list eligibility requirements or restrictions for people to use your services.

Intake Procedure Please provide a summary of your intake procedure.

Program Fees Please explain your fee structure (e.g., sliding scale based on income) and if you accept insurance (which types? Medicaid, Medicare).

Program Languages Please list any languages (other than English) that your program or service is provided in.

Handicap Accessible Is the program location handicap accessible?

Yes

Program Contact Please list the full name and title of the person to contact for updates to the program information.

Contact Phone

Contact Email

Fields with a * are required