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Agency Survey Form

FIRSTLINK of the Bluegrass, Inc. is an information and referral agency funded by the United Way of the Bluegrass and Lexington Fayette Urban County Government. We are a free service to individuals living in the Lexington, Kentucky area. We believe information about your organization would be a valuable addition to our database.

Thank you for agreeing to be in our database of service providers. It is very important that the information we have about your agency is accurate. The relevance of referrals to your organization depends on that accuracy.

1. Identify Your Agency
Agency Name
Director's Name and Title
2. Addresses
Street
City
State/Zip
If mailing address is different than physical address, please describe it here
Physical Address
Is the physical address the same as the mailing address? Check if yes.
Street
City
State/Zip
3. Contact Info for Clients
Phone
Fax
TDD/TTY
E-mail (please enter accurately)
Web-Site (please enter accurately)
4. Hours/Days
Hours to days:
Additional Programs or Services to days:
Other to days:

5. Description

Elaborate on the programs and services you provide. Callers are referred to your agency based on this description. Enclose a brochure or other literature in lieu of description.

6. Eligibility: (Criteria, ethnic origin, military, gender, disability, etc.)

7. Fees/Insurance

8. Intake (telephone, walk-in, by appointment, referral required)

9. Seasonal (seasonal programs, beginning of school, Thanksgiving, Christmas)

9. Satellites (Does your agency have any other locations that offers your programs?  Include hours and days.)

11. Update Contact Person
12. Affiliation? (with a larger organization)

13.  Funding?

14. Contact Info for Volunteers
Phone
Fax
TDD/TTY
E-mail (please enter accurately)
Web-Site (please enter accurately)
15. Volunteer Assignment Type
Start Date (for assignment)
End Date
16. Volunteer Position
17. Description of Volunteer Duties
18. Type(s) of volunteers appropriate for this position Groups
Court Referrals
Youth
Adults
19. Volunteer training available?   How often? No training available

Training available
How often offered?

20. Specific days and times needed?
21. Is the location of the volunteer opportunity handicap accessible? No answer
Yes
No

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Alliance of Referral Services logo unitedway.gif (3540 bytes) lexcare.gif (2788 bytes) lfucg.gif (3093 bytes)
FIRSTLINK of the Bluegrass does not endorse any agency or information listed, exclusion does not mean disapproval, all information on this website is subject to change and the agency cannot be held liable for out of date information. FIRSTLINK of the Bluegrass
1412 North Broadway Suite 206
Lexington, KY 40505
[606] 255-2374 [email protected]