Helpline Center Directory Intake Form

Choose the option that best applies:

Government OrganizationNon-Profit OrganizationFor-Profit OrganizationNative American AgencyMental Health Provider

Please list all sites below. To include additional sites, click on the "Add another site" button at the bottom of the entry. Repeat this until all sites have been added.
Site Listings*

Generic/Main resource email address (ie: info@youragency.com):
example@example.com
Website (or if no website, then can list Facebook page):
Please attach resource brochure if available.

Cancelof
Department/Agency Senior Administrator Name:*

First NameLast Name
Agency/Department Senior Administrator Title (ie. Executive Director, CEO, President, etc.):*
Agency/Department Senior Administrator Email:*
example@example.com
Do you want this email marked as private (not viewable by the public)?

YesNo
An annual update of program information is required. Who will be the annual updater?*

Senior AdministratorOther
Resource Updater Name:*

First NameLast Name
Resource Updater Title:*
Resource Updater Email:*
example@example.com
This signed release form will be kept on file as an ongoing authorization that the Helpline Center, Inc. may provide information to the public regarding the above-mentioned agency/organization. In addition to relaying information over the telephone, the Helpline Center, Inc. also disseminates information in a variety of printed and electronic formats including, but not limited to, human service directories, community resource sections in telephone books, computer disks, the Internet, and mailing lists/labels.

The above-mentioned agency/organization agrees to inform the Helpline Center, Inc. of any changes or discrepancies it makes or discovers and is solely responsible for keeping the Helpline Center, Inc. informed of changes, which may be needed in the information. This agency agrees to provide the Helpline Center, Inc. with updated information when it is requested.

This document shall be considered in place and valid until such time as the above-mentioned agency informs the Helpline Center, Inc. in writing that it is terminated.

The Helpline Center, Inc. has an inclusion policy that states “inclusion in the Helpline Center, Inc. database should in no way be construed to constitute an endorsement of an agency or organization or its service, nor should exclusion be construed to constitute disapproval. The information that appears in the Helpline Center, Inc. database is provided by the agencies and organizations. We make no representation with respect to the completeness of the information. The Helpline Center, Inc. reserves the right to remove or exclude any organization from the Helpline Center Inc. database for any reason. Inclusion in the Helpline Center, Inc. database is a privilege rather than a right.”
Signature

Clear
Print Name:*

First NameLast Name
Should be Empty:

Intake for Government Offices

Intake for Non-Profit Agencies/Programs

Intake for For-Profit Agencies/Programs

Intake for Native American Agencies/Programs

Intake for Mental Health/Substance Use Providers