Section 1 of 1 in this document
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
No
Full Address
Street Address
City
State
Zip
Fax Number
Brief Description of the Organization
Point of Contact
Website
Email
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
No
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
No
HIV/AIDS Services Offered
Birth Control Pills
Birth Control Patch (Ortho Evra)
Birth Control Shot (Depo-Provera
Birth Control Vaginal Ring (NuvaRing) Male Condoms
Female Condoms
IUD
Morning After Pill (Emergency Contraception) Pre-natal Care
Services are also provided in schools
ed|Family Planning Education
Family Planning Program Trainings
Other
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
Academic Support Services
Other
If Other
Faith Support Services
Counseling Services
Housing
Mentoring Services
Family Support Services
Other
If other
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