New Agency and Program Intake Form

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Please list all sites below where this program is offered. 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.

If the physical and mailing address are the same as the information entered for the agency, you can enter "same as agency address" for those fields but please ensure to complete the rest of the information such as phone numbers, hours/days of operation, and disability access. 

Dakota at Home has contracted with Helpline Center, Inc. to maintain the Dakota at Home Resource Database. The completion of this form will include your resource in the Dakota at Home Resource Database and the Helpline Center, Inc. Resource Database. 

This signed release form will be kept on file as an ongoing authorization that the Department of Human Services/Dakota at Home and 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.

The above-mentioned agency/organization agrees to inform the Helpline Center, Inc. or Dakota at Home of any changes or discrepancies it makes or discovers and is solely responsible for keeping the Helpline Center, Inc. or Dakota at Home 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.”