Phone Contacts Home Page e-mail ContactsUPCAP Services, Inc
Space
Space
Home Page
Space
UPCAP Information
Space
U.P. Area Agency on Aging
Space
U.P. Family Caregiver Network
Space
Long Term Care
Space
U.P. County Commissioners
Space
Housing Development
Space
Other Programs
Space
Events & Publications
Space
Provider Information

 

Space
Agency Resource Questionnaire
Space
Space
The information requested in this form will be used to refer callers throughout the Upper Peninsula of Michigan who are seeking services and volunteer opportunities in their communities. Your accurate detailed information will better help us refer callers appropriately and efficiently. PLEASE complete the online form below. After you complete this form, you will be given the opportunity to complete additional forms for additional programs and services your organization offers.

Questions? Contact Melissa Kositzky at UPCAP Services, Inc.: (906) 786-4701 or simply dial 2-1-1. We appreciate your participation in our database and look forward to referring our clients to your resources.

* Items marked with a red asterisk are required.

 Official Organization Name*:
  If incorporated, list name as it appears in the Articles of Incorporation
 
Program/Service Information
 Program/Service Name & Location*:
 
 Program Contact Person*:
 
 Telephone Number*:
 
 Services Offered*:
 
 Program Area Served*:
 
 Hours/Days that Services are available*:
   Please clarify
 
 Description of Program Services*:
 
 Application Procedure*:
   Appointment required? Call first? Walk-in? Referral required (from whom)?
 
 Eligibility*:
   Age, income, residency, etc
 
 Documents Required*:
   What types of information should a client bring to their first visit?
 
 Fees & Payment Information*:
   Are pay plans available? What insurance plans are accepted?
 
 Is the program seasonal or offered year round?*:
   If seasonal, please list dates available
 
Form Completion Information
 Form completed by*: Title*:
 
 Phone Number*: Date Completed*:
 
 Your e-mail Address*:
 
       
Space

Home || UPCAP Info || UPAAA || Family Caregiver Network || Long Term Care || UPACC || Housing Development || Other Programs