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Add Provider Information

Use this form to update the provider infomration. When you have completed your updates, click on the Save button. To return to the previous list, click on the Cancel button.

* Hold down the CTRL key to select more than one option.

Provider Information

County

Active

Name

Street Address

Street Address 2

City/State

Zip Code

Phone

Fax

TTY

URL

Email

Contact Information

Name

Title

Phone

Email

Areas Served

To select Areas Served, first select a County, then select one or more Areas by holding down
the CTRL key. Click on the » button to move Areas to the Areas Served box.

To remove Areas Served, select one or more Areas from the Areas Served box and click
on the « button.

County

Areas*

Areas Served*

What other locations do you serve?

English version:

Spanish version:

Services and Programs

To select the Services and Programs offered, click on a Service and select an associated Program.

Academic Enrichment

Academic Summer Programs
College Academic Preparation programs
College-Based or College-Level Course
GED Preparation Program
High School Academic Preparation Programs
Tutoring

Advising Services (Career College Vocational Apprenticeships)

Academic Planning/Counseling
Assistance with College Application
Career Assessment/Computer-Assisted Career Guidance
Career Counseling
Career Resource Center/Job Reference Library
College Admission Testing (Guidance Tutoring)
Financial Planning/Advising

Child and Family Intervention

Child Protection Services
Foster Care Services
Group Home Services
Intensive Family Preservation
Kinship / Extended Family
Other Services For Abused/Neglected Youth

Crisis Intervention

Crisis Lines
Emergency Telephone Response
Other Crisis Intervention Services
Rape Crisis Services

English as a Second Language (ESL)

English as a Second Language Program/Services

Family Planning

Pregnancy Counseling
Supportive Services
Teen Parent Services

Family Programs

Child Care For Youth Service Recipients
Family Life Education
Family Literacy
Family Strengthening Program
Other Family Programs
Programs For Parents

Food Assistance Programs

Food Pantry
Other Food Assistance Programs

Homeless Youth Services

Drop-In Services
Other Homeless Youth Services
Rental Assistance
Shelter Services
Transitional Housing

Introductory Career Exploration Services

Career Day/Career Fair
Career Field Trips/Workplace Tours
College Tours
Summer Jobs Program

Mental Health Services

Counseling Services
Day Treatment
Intensive Outpatient Treatment
Other Mental Health Services
Psychological/Psychiatric Rehabilitation
Residential Treatment Services
Support Groups
Therapeutic Outdoor Services

Mentoring

Adult Mentoring
Peer Mentoring

Personal Enrichment and Social Integration Services

Arts Music and Cultural
Community Service
Leadership Activities
Sports Programs
Technology Programs
Youth-led Programs

Physical Health Services

Disease Prevention Services And Education
Immunization
Other Physical Health Services
Prenatal Care
School-Based Health Clinic

Preferred Impairment Groups Served

Blind
Deaf or Hard of Hearing
Developmental Disability
Learning Disability
Mental Illness/Emotional
Mobility
Neurological
Other
Speech

School-Based Career Preparation Services

Career Clusters and Pathways
Career Focused Clubs/Activities
College Focused Clubs/Activities
Dual Enrollment
Employability Soft Skills Curriculum
Interviewing Skills
Junior Achievement
Student Enterprises

Substance Abuse Services

Addiction or Chemical Dependency Counseling
Assessment and Referral Services
Day Treatment
Diagnostic
Other Substance Abuse Services
Outpatient Treatment Services
Recovery Home
Residential Treatment Services

Transportation

Transportation Services

Violence Prevention/Education

Violence Prevention and Education Services

Work-Based Career Preparation Services

Apprenticeships
Cooperative Education (Work Study Programs)
Internship
Job Coaching
Job Placement
Job Shadowing
Job Training
Mentorship Program
Service Learning
Work-Based Learning Projects

Do your programs maintain a waiting list for services at this location?
Yes No

Please list the names and websites of all the programs offered for youth at this location:

Program Name

Program Website

Hours of Operation

Daily Hours of Operation*

Seasonal Hours of Operation*

Age Group & Target Population

Age Group*

Target Population*

If Other, please add here:

English version:

Spanish version:

Enrollment Information

Enrollment Status*

Eligibility Requirements & Language

Eligibility Requirements*

Language*

If Other, please add here:

English version:

Spanish version:

If Other, please add here:

English version:

Spanish version:

Additional Information

Comments

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Spanish version:
 

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