CHAIN HIV Treatment and Care Resource Directory
Directory Listing Form

Fill out this form to submit your agency information electronically. If you prefer to mail or fax your directory listing form use this PDF version. To view a PDF document download Adobe Acrobat Reader if you don't already have this software on your machine.

Agency Name:
Address:		City:
State:		Zip:
Phone: (xxx)xxx-xxxx		Fax: (xxx)xxx-xxxx
Toll Free Number:(xxx)xxx-xxxx		Hot Line: (xxx)xxx-xxxx
Email Address:		Web Site (URL):
Agency Hours:		Agency Contact Person:

Mission:
Client Eligibility:
Application Procedures:

Agency Type(which of these best describes your agency):
If you selected "Other" as "Agency Type" please specify that response here:

Area (for which Oklahoma area does your agency provide services):

Services (which of the following does your agency most often provide):
Access to Drug Therapy/Drug Education	Access to Services
Benefits/Financial Assistance	Case Management
Dental Care	Food/Pantry/Home Delivery/Food Vouchers
HIV Counseling and Testing	Housing
Legal Assistance	Medical Care
Nutritional Evaluation and Counseling	Substance Abuse/Mental Health Rehabilitation/Counseling
Support Group/Client Advocacy	Other:
If you selected "Other" as a "Service" please specify that response here:

Resources (does your agency provide any of the following):
Spanish Speaking Staff	American Sign Language Staff
TDD capability	Other:
If you selected "Other" as a "Resource" please specify that response here:

CHAIN HIV Treatment and Care Resource DirectoryDirectory Listing Form

CHAIN HIV Treatment and Care Resource Directory
Directory Listing Form