New Agency Request from Network of Care

Name of person providing the information below.

Email address of the person providing the information below.

Phone number of person providing the information below.

Agency Name

Did you find this form on the Network of Care website?

Yes
No

Are you a non-profit organization?

Yes
No

How long has your agency been in operation?

Are you a registered business?

Yes
No

If you operate a Sober Living Home, are you authorized by a City/Town to operate this type of facility?

Yes
No

If you answered Yes to the above question, please provide the name, phone number and email address of the representative from the City/Town Department you are working with. Also list any agencies that you are approved by (i.e. NARR, CCRR)

Site Name (if different than agency name):

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different than street address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Phone 2

FAX

TTY Number

Director Name and Title:

First Last

Email

Website

Hours:

Service hours, if different:

What languages are spoken at this site?

Does your agency/sites have disability access?

Yes
No

What features are available?

Braille in elevators
Handicap parking available
Handicap accessible bathrooms
Ramps
Wheelchair accessible
ADA compliant

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