If you are adding a new agency and service, please select “Yes” in the “New Agency and Service” field. New Agency and Service

If you are adding only a service (because your agency is already listed in the 211 database), please select “Yes” in the “Service Only” field, and “No” in the “New Agency and Service” field. Service Only

Physical Site Address 1

Physical Site Address 2

Physical Site City

Physical Site State

Physical Site Zip Code

Is the physical location confidential?

If the address is confidential, it will not be shared with the general public.

Is the facility ADA accessible?

Mailing Address 1. If different from physical address

Mailing Address 2

Suite, Room #, Building A, etc

Mailing City

Mailing State

Mailing Zip Code

Minimum Age Limits, if applicable

If no age limit, will default to 0

Maximum Age Limits, if applicable

If no age limit, will default to 105

Service Start Date

Service End Date

Type of Payment Accepted

Ctr + Left Click to Select Multiple Options

Payment Notes

Insurance Type Accepted

Ctr + Left Click to Select Multiple Options

Insurance Plans Accepted

Ctr + Left Click to Select Multiple Options

If other, specify below

Main Phone

After Hours Phone

Hotline Phone

Other Phone

TTD/TTY Phone

Fax

City

State

Zip Code

City

State

Zip Code

First Name

Last Name

Contact Phone

Contact Email

BY ENTERING MY INFORMATION BELOW, I VERIFY THAT ALL OF THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I HAVE READ AND UNDERSTOOD 2-1-1 SAN DIEGO’S INCLUSION/EXCLUSION POLICY LINKED ON THIS WEBPAGE AND WILL SUBMIT ALL FORMS OF PROOF OF LICENSURE AS REQUIRED BY REGULATING AGENCIES. I ALSO AM AWARE THAT APPLICATIONS WILL BE PROCESSED WITHIN 30-45 BUSINESS DAYS.

I UNDERSTAND THAT IN ORDER TO KEEP 2-1-1 SAN DIEGO’S DATABASE ACCURATE AND UP TO DATE, I AM REQUIRED TO INFORM 2-1-1 SAN DIEGO OF CHANGES TO THE AGENCY’S OPERATIONS WITHIN 30 DAYS.

I UNDERSTAND THAT 2-1-1 SAN DIEGO CONDUCTS AN ANNUAL SURVEY TO VERIFY CURRENT INFORMATION AND THAT IN ORDER TO REMAIN WITHIN THE DATABASE I MUST COMPLY WITH UPDATING THE INFORMATION UPON REQUEST. FAILURE TO COMPLY WITH THESE REQUIREMENTS MAY RESULT IN THE DEACTIVATION OF MY AGENCY OR AGENCIES SERVICES WITHIN THE 2-1-1 DATABASE.

First Name

Last Name