Charles County Community Resource Survey Question Title * 1. Name of Agency / Organization Question Title * 2. Sub-division within Agency (skip if not applicable) Question Title * 3. Service(s) Provided Housing Food Clothing Mental Health Extracurricular / Recreational Education Youth Adult Senior Family Support Prenatal/Expectant Parents Physical Health After Hours / Emergency Disability Substance Use Victim Services Employment Financial Assistance Other (please specify) Question Title * 4. What ages do you serve? 0-5 6-12 13-17 18-59 60+ Other (please specify) Question Title * 5. What insurance is required for your services? Medical Assistance / Medicaid Some Private Insurance None Fee for Service Other (please specify) Question Title * 6. Is there a limited number of times/ sessions a person can receive services? No If yes, (please specify) Question Title * 7. Are your services available multilingually? Yes No Question Title * 8. Please provide a brief description of your services and what they do Question Title * 9. Is there a waitlist? Yes No Sometimes If yes, how long is the average waitlist? Question Title * 10. Do you have "after hours" services? Yes No Question Title * 11. Is a referral needed? Referral needed Self referral No referral needed If yes, from whom? Question Title * 12. Agency Contact Information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 13. Please list links of your online content Question Title * 14. Thank your for completing the survey! Please designate a contact for content. Done