Name of Provider:
Type of Provider (Mental Health, Oral Health, Primary Care, Wellness, or etc):
Contact Person:
Address:
City:
State:
Zip:
Phone Number:
Ext.:
E-mail:

What services will your organization provide?

If offering school based services, please indicate what special needs or accomdations you will require. (Examples: sinks, confidencial space, adequate space for therapy session, etc.) Please explain below.

Location of services offered:

Onsite
School linked*

*If school linked, describe transportation plans:

Days and hours of services:

Extended hours

Yes*
No**

*If yes, indicate the days and the hours:

**If no, indicate coverage plans:

Are you a Medicaid Provider?

Yes
No

Are you currently providing CPS with services?

Yes
No

Are you currently providing services to any other school districts?

Yes*
No

*If yes, then please list the schools:

Are there any grants that will be utilized to provide these services?

Yes*
No

*If yes, then please list:

Thank you for offering your services, please hit submit form.