Reachout - Agency update form

Reachout maintains a comprehensive database of information resources for use in referring callers. Periodically, we ask all the agencies we list to update their information with us, to ensure that our service is as effective as possible.

The time is now! We're testing a new software package for our databases, so the update procedure may be a little different from what you remember. If you have any questions, please email us at update at reachouthotline dot org or call us at (315) 265-2422.

Items in purple are for our records only; they will not be shared with the public.

When choosing what to write, please try to include information that will be useful to callers of a 24-hour information and referral hotline. Mission statements are less helpful than specific descriptions of your programs, with information on eligibility requirements, specific services offered, fees, regional service area, etc. For example, hospitals with several outpatient clinics should include contact information, hours, and service offerings for each clinic, so we can give the information to callers.

We want to pass clients to you, but we can't do that without good information. The more detail you provide about your services, the more confident we can be in referring people to you, and the more likely they will be to call. Thanks for your help!

Information about you:
Your name:
Your title:
Your phone number:
Your email address:

Contact information for your agency:
Full name of agency:
Name and title of agency head:
Address(es):
Telephone number(s):
Fax:
E-mail clients may use:
Web site:
Office hours:
Summer hours (if applicable):

Information about programs and services your agency offers:
Services your agency provides:
Methods clients should use to contact you:	: Telephone : Walk-In : Referral : Letter : Call for appointment only : Other
Information or documents clients should be ready to present when calling for service:

Fees and restrictions:
Do you have fees for your service?	Yes No
If so, what do you charge clients for service?
Do you offer a sliding scale based on income?	Yes No
What are the upper and lower limits of the scale?
What insurance (if any) do you accept?	: Aetna : Blue Cross/Blue Shield : Champus : Empire Insurance : GHI : Guardian : Medicaid : Medicare : Met Life : MVP : Pomco : Travelers : Upstate : Value Behavioral Health : Others
What restrictions do you place upon your service (age ranges served, income, St. Lawrence County residents only, financial restrictions, etc.)?
Do you normally have a waiting list?	Yes No
If so, how long is your normal waiting list?

Thank you for taking the time to help us out! We really appreciate it.