Mental Health Association

2-1-1 ND Agency Registry Form

Organizations are the places to which clients are referred for additional information. Programs are specific services offered by an organization. For example, Mental Health America of North Dakota (formerly known as the Mental Health Association in North Dakota) is an organization. Programs/services offered by MHAND include the Resource Center, Public Policy and Advocacy and the 2-1-1 ND program.

If you have satellite offices, please complete an organization registration form for each satellite office, along with a program/service registry form for each program/service offered through their office. Please indicate "NA" for questions that do not apply.

NOTE: The 2-1-1 ND program has developed criteria for the inclusion or exclusion of organizations and programs in the resource database so that staff and the public is aware of the scope and limitations of the database. To request a copy of the inclusion/exclusion form contact Kristin Buchholz at MHAND.

Organization #
Organization's Legal Name, Other Names Known By, and Acronyms:
Name of Administrator/Director (include their title)
Street Address:
City:
State:
Zip:
Mailing Address: (if different)
City:
State:
Zip:
Telephone Number: (including TDD/TTY)
Toll Free Number:
Fax Number:
Email Address:
Website Address:
Days/Hours of Operation:

Please complete a separate form for each program/service you provide (ex. wheelchair loan, free glasses, companion program, emergency service, education, etc.). If some of the information is the same as the organization, please write "OR" in that space.

Program
Program/Service Name:
Program/Service Contact Person: (include their title)
Street Address:
City:
State:
Zip:
Mailing Address: (if different)
City:
State:
Zip:
Telephone Number: (Including TDD/TTY)
Toll-Free Number:
Fax Number:
Email Address:
Website Address:
Days/Hours of Operation:
Description of Service:
Target Population and languages other then English in which service is offered:

Application Process:
Eligibility Requirements and Exclusions, also describe any documents needed to apply:

Geographic Area Served:
Fee Structure for Service:
Payment Types Accepted:
Legal Status: (check one)	Non-Profit For-Profit Government Unincorporated Group


Thank you for taking the time to make sure the information in our database is up-to-date. Please contact us whenever significant changes occur. Your assistance in this regard allows us to be sure that those who are in need of your services are provided with accurate information!