Existing Community Services

Name of agency:______[Check all that apply.]  Campus organization  Health care facility  Community-based organization  Law enforcement agency  Correction agency (probation, parole, and  Mental health facility correctional facilities)  Sex offender treatment provider  Crime lab  State government  Educational institution  Tribal government  Faith-based organization  Other:______ Federal government

Contact person:______Title:______Street address:______City:______State:______ZIP:______Telephone:______Fax:______Email:______Hours of operation:______Fees:______

Branch/Satellite Office Contact person:______Title:______Street address:______City:______State:______ZIP:______Telephone:______Fax:______Email:______Hours of operation:______Fees:______

Services:  Accessible for individuals with disabilities  Medications (emergency contraception,  Child care etc.)______ Clothing  Multilingual  Community referrals  Prevention education  Counseling  Relocation assistance  Court advocacy  Support groups  Culturally specific  Shelter  Emergency funds  Transportation  Faith-based  Translation (certified interpreters)  Legal  Other: ______ Lock replacement  Other: ______ Medical care  Other: ______

Comments:______