<p> Georgia Coalition to End Homelessness 2009 Service Provider Questionnaire</p><p>This survey is designed to be completed by all homeless service providers and organizations that assist low income clients at risk of homelessness in Georgia. The information you provide will assist our organization in building a thorough database of homeless resources in Georgia. Thank you for taking time to complete this survey. </p><p>Prepared by: </p><p>Prepared for (legal organization name): Organizational Contact Information: Contact Name : Title: Email: Admin Phone: Admin Fax: Toll Free: Client Phone: Client Fax: Web Address: Senior Manager: </p><p>Mailing Address: City: County: State: Zip: </p><p>Street Address (if different from mailing – not applicable to DV or Child Protection Agencies) </p><p>City: County: State: Zip: </p><p>Hours of intake/operation: Intake process: Eligibility requirements (i.e. age, gender, population):</p><p>1 – Grandparent with children 5 – Two Parents with children 11 – Senior Female Adult 2 – Single Father with children 6 – Youth 13-15 12 – Senior Male Adult 3 – Single Mother with 7 – Youth 16-18 13 – Children 0-5 children 8 – Children in State’s Custody 14 – Children 6-12 4 – Two Parents-age limit on 9 – Single Male Adults 15 – Other: children 10 – Single Female Adults</p><p>Revised February, 2009 Information required at intake: Are any fees charged? No If yes, what fees are charged? Does your organization accept volunteers? No Volunteer coordinator’s name? Contact Ph/Email: Does your organization accept in-kind donations? No Does your organization accept financial contributions? No Is your facility handicap accessible? No Languages other than English spoken at your facility? </p><p>Which category(s) best describes your organization? (Please mark all that apply.) 1 – Nonprofit 2 – Government 3 – For-Profit A – Faith-based A – Local 4 – Other B – Community-based B – State C – Private C – Federal D – Other: D – Other </p><p>SERVICES PROVIDED (Please mark all choices that apply.) Referrals – Services NOT provided by the company 1 – Housing 6 – Advocacy/Public Education 2 – Financial Assistance – General/Housing 7 – Client Education/Employment Services 3 – Casework and Counseling 8 – Legal Assistance 4 – Children’s Support Services 9 – Transportation 5 – Medical Services 10 – Miscellaneous</p><p>Housing 1 – Permanent Shelter A - Affordable Housing D – Assisted Living Facility B – Permanent Supportive/Group Home E – Section 8 C – Skilled Nursing Facility/Nursing Home F – Other: 2 – Temporary Shelter A – Emergency Shelter 1 – 30 days or less 5 – Seasonal/Winter 2 – More than 30 days 6 – Runaway Shelter 3 – Natural Disaster 7 – Other: 4 – Domestic Violence </p><p>Revised February, 2009 B – Transitional Housing 1 – With Supportive Services 2 – Without Supportive Services 3 – Other: C – Hotel/Motel D– Halfway House/Recovery E – HIV/AIDS Housing F – Single Room Occupancy (SRO) G – Day Shelter/Respite H – Protective Custody I – Other: If your organization provides emergency shelter or housing: 1. How many persons is your organization able to accommodate each night? 2. How many spaces are available for the following? Men: Women: Children: 3. How many persons are currently on a waiting list to receive shelter or housing services? 4. Generally what is the average wait time on the waiting list? </p><p>Financial Assistance – General/Housing 1 – Rental Assistance 2 – Utility Assistance 3 – Temporary Assistance for Needy Families (TANF/DFCS) 4 – Supplemental Security Income (SSI), Supplemental Security Disability Income (SSDI) 5 – Benevolence/General Funds 6 – Mortgage Assistance 7 – Relocation Assistance 8 – Holiday Assistance 9 – Other: </p><p>Revised February, 2009 Food 1 – Meals 3 – Sack Lunches A – On-site 4 – Food Stamps (DFCS) B – Delivered/Meals On Wheels 5 – Food Stuffs/Angel Food Ministries C – Other: 6 – Financial Assistance/Vouchers 2 – Pantry 7 – Other: </p><p>Casework and Counseling 1 – Case Management 2 – Counseling A – Sexual Abuse, DV G – Addiction, 12-Step B - Veterans H – Mental Health, Mental Retardation, C – HIV/AIDS Developmental Disabilities D – Sexual Orientation I – Family/Parenting E – Religious J – Post Traumatic Stress Disorder F – Parole Rehabilitation K – Other: 3 – Support Group A – Sexual Abuse, Domestic Violence G – Addiction, 12-Step B – Veterans H – Mental Health, Mental Retardation, C – HIV/AIDS Developmental Disabilities D – Sexual Orientation I – Family/Parenting E – Religious J - Post Traumatic Stress Disorder F – Parole Rehabilitation K – Other: 4 – Other </p><p>Children’s Support Services 1 – Child Care B – Holiday gifts A – General/day C – Baby Supplies B – Before School D – Other: C – After School 3 – Summer Camps D – Other: 4 – Mentoring, Tutoring 2 – Donations 5 – In-House Child Protective Services A – School Supplies (DFCS) 6 – Other: </p><p>Revised February, 2009 Medical Services 1 – Immunizations 2 – Testings, Screenings, Health Fairs 3 – Medical Treatment A – General E – Physical Therapy B – Mental Health F – Dental C – Substance Abuse G – Optical (Eyeglasses) D – Home Health H – Other: 4 – Financial Assistance A – Bills B – Prescriptions C – Government (Medicare, Medicaid, Peachcare, etc.) D – Other: 5 – Other: </p><p>Advocacy/Public Education 1 – Homelessness 8 – Addiction Issues 2 - Sexual Abuse, Domestic Violence 9 – Mental Health, Mental Retardation, 3 – Veterans Developmental Disabilities 4 – HIV/AIDS 10 – Homeless Families 5 – Lesbian, Gay, Bisexual, Transgendered 11 – Physical Disabilities 7 – Prison Reform/Ex-offender 12 – Other: </p><p>Client Education/Employment Services 1 – Employment 4 – Parenting Support A – Assessment 5 – Health B – Training 6 – Language/Literacy C – Placement 7 – GED Preparation D – Resume Assistance 8 – Financial/Tuition Assistance E - Other: 9 – Computer Training 2 – Life Skills 10 – Other: 3 – Financial, Budgeting</p><p>Revised February, 2009 Legal Assistance 1 – General 6 – Immigration 2 – Child Support/Custody 7 – Public Benefits 3 – Temporary Protective 8 – Housing Orders/Domestic Violence A – Accessibility 4 – Discrimination B – Landlord/Tenant 5 – Criminal Cases C – Other: </p><p>Transportation 1 – Organizational 3 – Voucher/Financial Assistance A – Medical 4 – Car Repair/Insurance Assistance B – Employment 5 – Assistance in Obtaining Driver’s C – To/from organization License/ID D – Other 6 – Other: 2 – Bus/Train tickets, tokens</p><p>Miscellaneous 1 – Assistance in Obtaining ID 2 – Client Computer Access 3 – Client Phone Messaging System 4 – Client Mailing Address 5 – Client Showers 6 – Client Restroom 7 – Clothing Closet 8 – Furniture Bank 9 – Housing Repairs 10 – Prison Outreach 11 – Other: </p><p>Revised February, 2009</p>