This form is being used to collect information on legal services programs that collaborate with non-lawyer agencies to improve service delivery. If your program collaborates with non-legal agencies for a common purpose such as systemic change or coordinated services please fill out this form. A "collaboration" is defined as a relationship somewhat more structured than simple mutual referrals but would include programs where mutual referrals are part of a coordinated intake plan.

Name of Program:
Address:
City:
State:
Zip:
Telephone:
Fax:
Contact Name:
E-mail:
Website Address:
Is your Collaboration with:
a single agency: a small number of agencies:
a large number of agencies: formal coalition :
  other (specify) :


Please indicate which type of agencies your partners include(check all that apply)
AIDS Children's Program Domestic Violence
Alcohol/Drug Abuse Homeless Food/Nutrition
Immigration Medical/Health Related Mental Health
Transportation Religious Housing
Fire Dept Police Dept Counseling
Employment Discrimination Long Term Care
Community Economic Development Education/Schools (non-law)  
Social Services Consumer Education  
Other(specify)
Other(specify)


The Collaboration works on the following issues(check all that apply)
Consumer (Specify)  
Family (Specify)  
Health (Specify)  
Housing (Specify)  
Wills, Estates, Probate (Specify)  
Education (Specify)  
Juvenile (Specify)  
Income Maintenance (Specify)  
Individual Rights (Specify)  
Employment and Pensions (Specify)  
Immigration (Specify)  
  Other (specify) (Specify)  
  Other (specify) (Specify)  



Briefly describe Collaboration:

 

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