Agency Information Form
This form is to be completed by any Knoxville-Knox County agency that wants their agency information listed on the community-wide housing online directory www.knoxhousinghelp.com

This form can also be used by KnoxHMIS partner agencies in order to update or add new agency/program information. If you are a KnoxHMIS partner, please make sure you know your funding sources and any applicable grant numbers and their start and end dates before starting this form.

This form should take 15 minutes or less to complete per program.

If you have questions about this form, please contact hmissupport@utk.edu

Email address *
Agency Name *
Your answer
Program Name *
Your answer
Contact Name (person completing this form) *
First and last name
Your answer
Contact Phone *
Format is ###-###-####
Your answer
When did/does this program begin? *
MM
/
DD
/
YYYY
Agency/Program Description *
Your answer
Office Phone *
Format is ###-###-####
Your answer
Fax Number *
Format is ###-###-####
Your answer
Physical Address *
Your answer
Mailing Address *
Your answer
Primary Contact's Name *
Please list the lead staff, case manager, or primary referral contact here.
Your answer
Primary Contact's Title *
Your answer
Primary Contact's Email *
Your answer
Days and Hours of Operation *
Your answer
Agency Website Address *
Your answer
Eligibility Criteria for Services *
Please list what is required in order for a person to receive services from your agency or program (e.g. age limit, income limits, etc.)
Your answer
Intake/Application Process *
Please list any documents that individuals will need at intake (e.g. valid identification, birth certificate, case management referral, etc.)
Your answer
Program Limitations
Please describe any limitations you have for providing services (e.g. up to 90 days, two times in a year, ex-offenders, etc.)
Your answer
Spoken Languages *
Your answer
Does your agency require that a person have insurance in order to receive services? *
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