Agency Registration and Resource Updates - Crisis Intervention Center

The goal of Crisis Intervention Center is to be a resource not just for consumers, but for the agencies that provide services and their supporters. To that end, we offer a streamlined process for applying for inclusion or updating data contained in our community resource databases. Please complete the form below so that we can either add your organization to our database or update agency and program information that may have recently changed.

Request being made*

Agency Name*

Program Name*

Description of Services*

Please provide a brief description of the services your agency/program offers. You may attach additional documents below if necessary.

Please feel free to update any documents that tells us more about you agency

Drop files here or

Information Provided for a Referral

Please complete all the required contact fields as this information is given out as part of a referral to the agency or program.

Main Number*

Alternate Number

Fax Number

Toll Free Number

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is physical address same as mailing address?*

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agency Website*

Agency Email*

Enter Email Confirm Email

Hours of Operation*

Areas Served (Parishes, Cities or Zip Codes)*

Eligibility for Services*

Fees*

Intake Process*

Languages Spoken*

Name & Title of Program Director*

Is the facility handicapped accessible?*

Do you wish to be included on website?*

Do you wish to be included in resource directory?*

What is the status of your organization? (check all that apply)*

Non-Profit (501c3)
State Entity
City/Parish Government
Faith-Based Non Profit
For-Profit Business
United Way Agency

Contact Information needed for Annual Resource Update

The information below remains unpublished and is only accessible to the Resource Department for purposes of updating agency/program information; it is never given out to callers.

Contact Person*

First Last

Title*

Email*

Enter Email Confirm Email

Phone*

How do you prefer to be contacted for updates?*

Would you like to receive quarterly system advocacy reports?*

Email for advocacy reports

A system advocacy report is an aggregated statistical analysis of needs, referrals, and parishes of clients served by Crisis Intervention Center Inc.

Enter Email Confirm Email

Terms and Conditions*

I Agree
I Do Not Agree

By signing this form, you are agreeing: 1. You are authorized to add your agency’s information for use in Crisis Intervention Center, Inc. Resource Database. 2. The information on this form is current and accurate. 3. When contacted annually by Crisis Intervention Center, Inc., you will provide updated information for your provider. Failure to provide updated information may result in removal from the resource database. 4. Your agency’s description of service may be altered or abbreviated to fit within the Crisis Intervention Center, Inc. Official Style Guide for Resource Database Providers. 5. You will communicate any changes in information or services to Crisis Intervention Center, Inc. by contacting the Crisis Intervention Center’s Resource Department.

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Resource Updates and Additions

Information Provided for a Referral

Contact Information needed for Annual Resource Update