222 S. Riverside Plaza, Suite 1900, Chicago, IL 60606
Contact: Monica L. White, Program Manager 312-906-6033 or
Jessica Papp, Program Specialist 312-906-6024 for more information.

2007/2008 Community Services Directory
Registration Form
(Agency/ Clinic/Healthcare Provider)

Section A
Agency/Provider Name
Practice Name
Contact Person
Address
City
State
Zip Code
Complete Phone Number
Complete FAX Number
Complete TDD#
E-mail Address
Website
Hospital Affiliation(s)
 
Provider Type:
 (1)Physician  (2)Pharmacist  (3)Alternative
 (4)Mental Health  (5)Dental  
 
(For Each Section - Check All That Apply)
Medical Specialties: Alternative Therapies: Mental Health:
 Allergy  Obstetrics/Gynecology
 Cardiology  Ophthalmology
 Dental  Optometry
 Dermatology  Orthopedic
 Family Practice  Otolaryngology
 Gastroenterology  Pediatric
 Infectious  Plastic Surgery
 Internal Medicine  Podiatry
 Neurology  Psychiatric
 Other: 
 Other: 
 
 Acupuncture
 Chiropractor
 Exercise
 Homeopathy
 Hypnotherapy
 Massage
 Meditation
 Nutrition
 Reiki
 Tai Chi
 Yoga
 Other: 
 Addiction
 Couples
 Depression/Suicide
 Domestic
 Family
 Grief/Loss
 Group
 Individual
 Relationships
 Sexual Identity
 Sexual Issues
 Other: 
 
Pharmaceutical Services: Languages Spoken: (Please List)
 Allergy  Obstetrics/Gynecology
 Cardiology  Ophthalmology
 Other: 
 
Section B
Agency/Practice Description: (Please provide a brief description of the services your agency/practice offers.)
 
Include agency/practice in Spanish directory?  Yes     No
 
If yes, provide a Spanish Agency/Practice Description below.
 
Section C
Geographic Location: (This refers both to your physical location and your service area. Check all that apply.)
(A) Downtown (D) West Side (G) South (J) Illinois
(B) North Side (E) North (H) Southwest (K) National
(C) South Side (F) Northwest (I) West  
 
Section D
Fees: (Check all that apply.)
(D) Medicaid (F) Free (P) Public Aid Accepted
(E) Set Fee (I) Private Insurance (Q) Medicare
(S) Sliding Fee Scale  
 
Section E
 Yes     No Evening/Weekend Hours Available? (Check One)
 Yes     No Is the Facility Handicap Accessible? (Check One)
 Yes     No Are Transportation Services Available? (Check One)
 
(Optional Information)
Are you currently accepting new patients?   Yes     No
 
Is your organization accredited? If so, by what organization(s)?
 
What were the findings of your last consumer/client satisfaction survey? What number of people were surveyed?
 
What is the average wait time for an appointment in your clinic/practice, etc.?
 
What documentation should a potential client/patient bring with them to their first appointment?
 
Any other information you would like to add about your agency/practice/clinic?