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Directory Information Update

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General Information

* Agency Number:
* Agency Name
Acronym
* Executive Director/ CEO
* Total Operating Budget $
* Street Address
PO Box (where applicable)
* City
* State	* Zip
* E-mail
Web site
* Telephone
Fax
Toll Free Phone
TDD Phone

Identify areas your agency has experience in and would be willing to share with other providers. (Please check all that apply)

Self-Direction, Consumer Choice, Advocacy	Marketing, Branding & Positioning your Agency in the Community
Diversifying Funding Streams	Nonprofit Board Development, Working Effectively with your Board
Establishing & Maintaining a Values-Driven Culture	Performance Excellence, Quality Management & Benchmarking
Fiscal Management, Cost Effectiveness Strategies	Recruiting, Selection & Retention
Fundraising & Agency Development	Succession Planning & Transitioning
Innovative Consumer Services & Service Delivery Options	Training & Supervision
Innovative Technology Applications	Transitioning Services Delivery
Leadership, Management Development	Other

Contact Information

Admission Contact Name: Title: E-mail:	Human Resources Contact Name: Title: E-mail:
Finance Contact Name: Title: E-mail:	Information Technology Contact Name: Title: E-mail:
Government Relations Contact Name: Title: E-mail:	Purchasing Contact Name: Title: E-mail:

Agency Information

Nonprofit

Proprietary

Number of Direct Support Staff: Full-time: Part-time:

Average entry level DSP wage per hour:

Average DSP wage per hour:

Total Number of Employees (front-line DSP and admin/management)

Is your agency unionized?

Accreditation: CARF COA CQL
Other

Age Range of Individuals Served

Total Number of People Receiving Any Supports

Total Number of People Receiving Employment/Vocational Services

Total Number of People Receiving Residential Services

Total Number of People Receiving In-Home Supports

Total Number of People Receiving Respite Services

Number of Residential Sites

In which states do you provide services?

In which federal congressional district(s) do you provide services?

In what international locations are you involved?

Adult Residential (Please check all that apply)

Adult Residential Options

Crisis/Short Term Transition Group Home 1-2 people 3 or more people Respite	ICF/MR/ICF/DD 4-15 people 16 or more people
Host Home/Foster Care	Own home
Habilitation/DayHab

Adult Supports

Companion Living	In-Home Supports
Supported Living	Technological In-Home Supports (In-home monitoring services with audio/video equipment)

Aging Services (Please check all that apply)

Companion Living	Homemaker/Housekeeper Services
Home Health	Hospice (In-Home)
In-Home Assistance (Personal care, semi-home health, respite, attendant care)

Aging Services Options

Assisted Living	Day Services
Group Home 1-4 people 5 or more people	Nursing Home Licensed Nursing Facility Skilled Nursing Facility
Hospice Facility Based	Host Home/Foster
Own Home

Chilren's Services Supports(Please check all that apply)

Family Supports (Services occur in the individual's home)	In-Home Supports
School-Based and Educational Supports

Children's Services Options

Host Home/Foster Care Home	Own Home
Group Home 1-2 people 3 or more people	Respite Home Treatment/Therapeutic Foster Homes

Clinical Services (Please check all that apply)

Crisis Intervention	Dental Services
Early Intervention	Family Preservation Services
Family Support Educational Services	Grief Therapy
Intensive Behavioral Services	Nursing Supports
PCP Facilitation Services	Pyschological Evaluations
Outpatient Counseling Therapy (Music, occupational, physical)

Educational Supports and After School Programs/Facilities (Please check all that apply)

Adult Education	Alternative Schools
Daycare	Early Intervention
Pre-Schools	Summer Program

Employment/Day Supports (Please check all that apply)

Community Based Employment Supports

Competitive Employment with Non-Job Coaching and Employer Health insurance	Micro-Enterprise
Individual Supported Employment	Vocational Rehabilitation
Services/Evaluation	Enclave (Small group working at a business with provider supports)
Group Supported Employment	Entrepreneurial

Facility/Site-Based

Workshop

Ability One/J-WOD

Operational Programs

School-to-Work Transition	Internships
Volunteerism

Funding Sources (Please check all that apply)

MEDICAID: ICF/MR HCBS Waiver Rehab State Plan Services
Other Medicaid (e.g. Clinic EPSOT, etc. please list:

1115 Waiver	Private Insurance
Farmers Home Administration	Private Pay
Food Stamps	Section 1915 (i)
Fundraising	Section 1915 (j)
HUD 202	SSA Ticket to Work
HUD 811	SSDI
HUD Section 8	SSI
Title XX Social Services	Veterans Administration
Welfare-to-Work/TANF	Vocational Rehabilitation
Workforce Investment Act	Other
MR/DD Local MR/DD State MR/DD

Self-Directed Services/Professional Services (Please check all that apply)

Adaptive Environment	Case Management/Support Coordination
Cooperatives	Durable Medical Equipment
Employer Agent	Fiduciary Services
Fiscal Agent	Guardianship Services
In-Home Supports	Micro-Boards
Professional Services Transportation	Service Broker Services

Special Populations (Please check all that apply)

Aging	Autism
Chronic Health (MS, ALS, etc.)	ID/DD
Mental Health/Mental Illness Substance Abuse TBI	International/Cross Cultural Educational & Technical Services Residential Services