Profile # _____________                                                  Date:_________________________

Name of Agency:_________________________________________________________

Address:________________________________________________________________

Phone:______________________  Contact Person:______________________________

Department and Title of Contact Person:_______________________________________

Agency Hours:___________________________________________________________

Interview by (circle one):  phone                      in person                   in class

I verify that I have spoken with this contact person:______________________________

                                                                                              (Your signature)

Services provided by the agency and/or department:

Who is eligible for these services?

How do clients learn about these services?

Who pays for these services and how is the agency funded?

When was the agency established?

Mission statement/statement of purpose:

Other information of interest:

Additional contact people: