Chicago Area HIV/AIDS Services Directory Update Form

You must provide us with the name of your agency

Agency Name: 
 
Contact Person: 

Address: 

City:  State: Zip:

Complete Phone # Complete TDD #

E-Mail Address: WWW Page:

 

Agency Description   (provide a brief description of the HIV services your agency offers)

 

Check here to include in Spanish Section  (Check only if agency offers service in Spanish)

 
Geographic Location:     Where is your organization located? (Place a X in only 1 unless there are sites in other areas)

A - Downtown Chicago       D - Chicago West Side  F - South Suburbs  H - Illinois

B - Chicago North Side      E - North Suburbs          F - Southwest Suburbs   I - National

C - Chicago South Side     E- Northwest Suburb       G - West Suburbs

What Neighborhood or suburb is the agency located in ? 
Service Area 

Fees:   E= Set Fee  F=Free  I=Private Insurance  P=Public Aid Accepted  S=Sliding Scale

People Served:    A=Aids diagnosis only     D=Handicap Accessible  N=Incarcerated   W=Women Only
                                                                 B=Bilingual (Specify Language)       H=HIV diagnosis            T=Transgendered X=All populations
                                                                 C=Children(0-12)             M=Men   Y=Youth(13-24) V= Veteran    Y=Youth

Services your organization provides (Please type a Y for Yes and N for No in the boxes below)

1) Alternative Health     8) Financial Assistance     15) Information              22) Substance Abuse
2) Case Management    9) Food Basic Needs         16) Legal Assistance     23) Needle Exchange
3) Children And Family 10) Foster Care                  17) Long Term Care      24) Testing & Counseling
4) Clinical Trials            11) Home Health Care      18) Medical Care           25) Transportation
5) Day Respite Care     12) Hospice Care               19) Mental Health         26) Volunteer Support
6) Dental Care               13) Hospitals                      20) Pastoral Care          27) Volunteer Support
7) Education Programs  14) Housing                        21) Public Assistance


(click here on "submit" to send the info you entered into the boxes above.)