2-1-1 El Dorado County

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Program Application

    Only use this form to add new program if your agency is already in the 211 El Dorado Database. Otherwise, CLICK HERE to submit your agency application. Thank you for having your agency and program listed in the 211 El Dorado database.



    A field name with an asterisk (*) indicates a required field.

    Your Name*

    Your Email Address*

    Your Agency Name* (in 211 El Dorado database)



    New Program Information

    Program Name*

    Program Description* (maximum of 100 words)
    (e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school.)

    Program Residency Requirement*

    Program Eligibility*

    Language Offered*
    EnglishSpanishOtherInterpreter Services Available

    Other languages (if choose “Other” in the previous question)

    Program Fees*
    No feeFees vary based on incomeFees vary based on servicesSliding scale fee based on incomeSet program feeAccepts Medi-CalAccepts MedicareAccepts most insuranceMembership fee

    Fee information (explain fee range for sliding scale, fees vary, set program fee, membership fee, etc.)

    Program Intake Procedure*

    Additional notes on Intake Procedure (e.g. Clients must be referred by a school counselor.)

    Document Required at Intake* (e.g. ID, SSC, Proof of Income, etc.)

    Program Website

    Program Hours*

    Program Phone Number 1* (required) and phone description (e.g. 530-111-1111 Main Number)

    Program Phone Number 2 (if any) and phone description (e.g. 530-111-2222 Placerville Office)

    Program Phone Number 3 (if any) and phone description

    TDD/TTY Number (if any)

    Program Physical Address 1* (required) where the service is offered

    Is this location wheelchair accessible?* YesNo
    Is this location confidential?* YesNo

    Program Physical Address 2 (if any) where the service is offered

    Is this location wheelchair accessible? YesNo
    Is this location confidential? YesNo

    Program Physical Address 3 (if any) where the service is offered

    Is this location wheelchair accessible? YesNo
    Is this location confidential? YesNo

    Program Mailing Address*



    Additional Information

    If you do not hear from us within 5 business days after submitting your application, please contact us at 211eldorado@icfs.org. Thank you.

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    2-1-1 El Dorado County
    is provided by the County of El Dorado’s Health and Human Services Agency.