211 Ventura County

Help is just a click away

  • Home/Inicio
  • About Us/Sobre Nosotros
  • Reports
  • Contact Us/Contactenos

Agency Application

    Thank you for your interest in having your agency listed in the 211 Ventura database. If your agency is not in the 211 Ventura database, please use the form below to submit your application.
    A field name with an asterisk (*) indicates a required field.

    Does your organization provide services that are appropriate for inclusion in the 211 database, based on the 211 Ventura County Inclusion/Exclusion Policy? YesNo

    Have you been in operation for at least six months?YesNo

    Your Name*

    Your Email Address*

    Agency Information

    Agency Name*

    Agency Description* (describe your agency in one or two sentences)
    e.g. Nonprofit organization focused on supporting low-income families in Ventura County.

    Agency Type*

    Agency Website

    Agency General Email (for public use)

    Physical Address*

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

    Mailing Address*

    Administration Office Hours*

    Agency General Phone Number*

    TDD/TTY Number (if any)

    Agency Primary Contact Information

    (The best person for 211 to contact with questions about your service or to update the 211 record.)

    Agency Primary Contact Name*

    Agency Primary Contact Title*

    Agency Primary Contact Email*

    Agency Primary Contact Phone Number*

    Agency Senior Executive Information

    (i.e. Organization Executive Director/CEO/President)

    Senior Contact Name

    Senior Contact Title

    Senior Contact Email

    Senior Contact Phone Number

    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* (e.g. Must be parents with children under 18 years old.)

    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. 805-111-1111 Main Number)

    Program Phone Number 2 (if any) and phone description (e.g. 805-111-2222 Oxnard 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 211ventura@icfs.org. Thank you.

    To provide information about another program,  CLICK HERE after you submitted the Agency Application. Thank you.
    Scroll Up

    ¡Envíe un mensaje de texto a MIDINEROVC al 211-211 para recibir recordatorios de impuestos!

    Text MYMONEYVC to 211-211 for tax deadline reminders!