[DC GOVERNMENT] DBH Service Provider Submission Profile Form

DBH Service Provider Submission Profile Form

Your organization is either already included in the DBH Resource Guide or you have indicated interests in being included in the guide to participate in the Provider Network. In order to make sure that we have the correct or updated information for your organization, we need for you to complete this profile form.

Organization's Name

Are you a part of the provider network

Yes

Fax Number

Brief Description of the Organization

Point of Contact

Website

Hours of Operation

Please check all that apply

Our organization provides confidential services

Our organization provides anonymous services

Both

Neither

What documents are needed to receive the service? (i.e. photo I.D.)

Insurance Coverage Needed?

Yes

What is the cost associated with the visit?

Language(s) Spoken

English

French

Spanish

Amharic

Chinese

American Sign Language

Other

If Other

Age Group of Youth Served

Parent/Guardian Consent Needed?

Yes

If Other

How are the HIV Services Offered: (Please check only one)

Appointment Only

Walk-ins

Welcome Referrals On

How are the Family Planning Services Offered?

Appointment Only

Walk-ins

Welcome Referrals On

STI Services Offered

Testing

Treatment

Counseling Education Training

Services are provided in schools

Other

If Other

How are the STI services offered

Appointment Only

Walk-ins Welcome

Referrals Only

Mental Health Services

Drug Abuse Support Services

Counseling Services

Suicide Prevention Support Services

Alcohol Abuse Support Services

Other

If Other

Academic Support Services

Tutoring

College Assistance

Mentoring Services Career Development

Other

If Other

Dating and Relationships

Education on Healthy Relationships

Teen Dating Violence Prevention

Dating|Teen Dating Violence Support

Legal Advise and Support

Other

Public Assistance

Housing

Food Stamps

Medicaid/Alliance

Teen Parenting

Services

LGBTQ Services

Bullying Prevention

Sexual Health Services

Counseling Services

Mentoring Services

Family Support Services

Academic Support Services

Housing

Career Development

Homeless Youth

Housing

Foster Care

Family Support Services

Academic Support Services

Other

If Other

Faith Support Services

Counseling Services

Housing

Mentoring Services

Family Support Services

Other

If other

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