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KC•Connect Questionnaire

Keep us informed of changes in your services or addition of new programs.

If you have questions, please contact Mary Karch or Michelle Brown at 816/474-4240.

Tell us about your organization
Organization name:
Office address:
City, State, Zip:
Mailing address, if different:
City, State, Zip:
Telephone number:
TTY number:
Toll-free number:
Fax number:
E-mail address:
Web site URL:
Contact person:
Title:
Type of organization: Non-profit
For-profit
Government agency
Sectarian, church affiliation
Other:
Languages:

Do you have any eligibility restrictions for participation in your service/program?
Age restrictions:
Income restrictions:
Residency requirements:
Medical condition:
Other:
What documentation is required to access your service/program?

 
Proof of age:
Proof of income:
Proof of residency:
Benefit award letters:
Other:
What are your payment sources?
Private pay
Private insurance
Voluntary contributions
Medicare
Medicaid
Social Services Block Grant
Veteran's Administration
Sliding fee scale
Other
What areas/counties do you serve?
What are your hours?
About Your Services
What services do you provide?

Please list all services provided by your agency. If you have special programs, branch offices, or services with different requirements, please indicate this in the "Special requirements" space below. Please be as specific as possible when completing this form.

Space is provided for up to 10 services. Please fill in what you need and leave the others blank.

 
Service 1:
Brief
description:
Special requirements:
Service 2:
Brief
description:
Special requirements:
Service 3:
Brief
description:
Special requirements:
Service 4:
Brief
description:
Special requirements:
Service 5:
Brief
description:
Special requirements:
Service 6:
Brief
description:
Special requirements:
Service 7:
Brief
description:
Special requirements:
Service 8:
Brief
description:
Special requirements:
Service 9:
Brief
description:
Special requirements:
Service 10:
Brief
description:
Special requirements:

 

After you submit the form, you will receive a confirmation notice. You may want to print a copy for your records.