Provider Sign-Up Form Participant Info Organization Name Is the organization a Domestic Violence Action Center (DVAC) partner? Is the organization a Domestic Violence Action Center (DVAC) partner? Yes No Is the organization represented on the Fairfax County Council to End Domestic Violence? Is the organization represented on the Fairfax County Council to End Domestic Violence? Yes No Organization Description Organization Website Parent Organization Sub-Organizations Address City State Zip Code Phone Your primary contact number Email Address Primary Contact for Inter-Agency Referrals and Questions Primary Contact Title Primary Contact Name Primary Contact Phone Primary Contact Email Note any special instructions about primary contact Include any instructions for agencies making referrals. Localities Served Localities Served (Check all that apply) Localities Served (Check all that apply) All Fairfax County South County Reston Area Bailey's Crossroads Culmore City of Fairfax City of Alexandria Town of Herndon Town of Vienna Arlington County Prince William County Loudoun County Maryland District of Columbia Other Services Provided Services Provided (Check all that apply) Services Provided (Check all that apply) Support Groups Peer support for adults Training/technical assistance Outreach/prevention education Victim Advocacy Court accompaniment (criminal) Court accompaniment (civil protective orders custody) Crisis Intervention Hotline Counseling services for children Counseling services for adults Psychiatric services Substance abuse treatment/support Forensic medical exam/services Medical services First Responder Law Enforcement Court services Offender services and treatment Batterer Intervention Classes Military-active duty Veteran services Basic Necessities (food clothing financial) Employment services Long-term case management ESOL classes Child care Parenting education Pet-related services Pet shelter Culturally-specific services Legal advice/information Legal representation (pro bono) Legal representation (sliding scale) Legal representation (standard fees) Immigration legal assistance Emergency shelter Transitional housing Long-term/supportive housing Housing advocacy Other Languages Spoken Languages spoken by staff/advocates Does this agency have access to telephone interpretation services? Does this agency have access to telephone interpretation services? Yes No Languages spoken by staff/advocates (Check all that apply) Languages spoken by staff/advocates (Check all that apply) English Spanish Korean Arabic Vietnamese Chinese Farsi Amharic Tagalog Hindi Urdu French American Sign Language (ASL) Other Accepting Applications Currently accepting new applications? Currently accepting new applications? Yes No Application Instructions - How to apply? Hours of Operation Does the agency charge fees for any services? Does the agency charge fees for any services? Yes No If yes, describe fees Eligibility Restrictions Describe any eligibility guidelines (for example, eligible income levels) Describe any restrictions on eligibility (for example, Fairfax County residents only) Agency Special Services Skills Agency special services skills (Check all that apply) Agency special services skills (Check all that apply) Hearing impairment Visual impairment Autism Children with disabilities Cognitive impairments Trauma-informed counseling/therapy Substance abuse counseling/therapy Substance abuse recovery LGBTQ issues Mental health first aid Mediation Jury trials Sexual violence Human trafficking Other Agency Target Populations Identify your Target Population(s) Identify your Target Population(s) Persons with disabilities Persons living with HIV/AIDS Active duty military and families Veterans LGBTQ persons Immigrants/refugees Children (12 and under) Youth (13-24) Multilingual Religious group (specify) Culturally specific group (specify) Homeless persons Women and girls Men and boys Formerly incarcerated/reentry Elders Substance abuse recovery Other Volunteers, Optional Temporary Operating Status, Updating Agency's Information Accepting volunteers? Accepting volunteers? Yes No Types of Volunteers Optional temporary operating status/headline on agency page (For example, SERVICES CURRENTLY AVAILABLE BY PHONE ONLY.) Who will be responsible for updating agency's information in the online resource database? Updater's email Updater's Name Visibility Please select if related information should be hidden from the public Please select if related information should be hidden from the public Organization Address Organization Phone Number Primary contact information Instructions for agencies making referrals Accepting new applications Application instructions-How to apply Hours of Operation Agency Fees Agency Fees Description Eligibility restrictions Eligibility guidelines Specialized competencies Target populations