Provider pilot

Provider Pilot Intake

About 10 minutes. Share only information needed to build and manage your public HelpSignal listing. Do not submit client records or sensitive client information.

Public listing information

Only submit public provider information. Do not submit client records, medical information, case notes, Social Security numbers, immigration documents, or other sensitive client information.

Legal organization name *

Use the full legal name of the participating organization.

Public-facing name

Organization type

Public website

Public email address

Public phone number

Main public address

Address display preference

Additional service locations

Optional. One location per line.

Service area

Programs or service categories

Main resource or service name

Main service category

Public description

Services to list publicly

Operational contacts and service details

Authorized representative name *

Authorized representative title

Authorized representative email *

Authorized representative phone

Best number for pilot follow-up and provider operational messages if you opt in.

Hours

Eligibility requirements

Appointment or walk-in requirements

Walk-in welcome

Appointment required

Referral required

Pet-friendly

Wheelchair accessible

ID waived for a first visit

Spanish-speaking staff available

Documents people may need to bring

Languages available

Accessibility information

Transportation information

Current service instructions

Emergency or after-hours instructions

Standard public note

Internal or never-public details

Status workflow and reminders

Status categories your team will use

Current availability

Closing time or cut-off detail

Next distribution, meal, or appointment detail

Capacity status detail

Walk-in status detail

Call-first instruction

Special status instructions

Recent eligibility changes

Anything else we should know?

Primary updater name

Primary updater title

Primary updater email

Primary updater phone

Backup updater name

Backup updater title

Backup updater email

Backup updater phone

Preferred reminder method

Permissions, communication consent, and signature

I confirm this information may appear publicly on HelpSignal, except items clearly marked as internal or never-public. My organization remains responsible for its public information and status updates, and may request edits or removal at any time. *I understand HelpSignal does not request client records, medical information, protected health information, Social Security numbers, immigration documentation, case notes, or other sensitive client information for this pilot. *My organization agrees to remove access or ask HelpSignal to remove access when staff responsibilities change or staff leave the organization. *I agree to receive provider operational text messages from HelpSignal about onboarding, listing verification, status reminders, service updates, and confirmation of submitted status updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. Reply HELP for help. Consent is not required to participate.I agree to receive provider operational email reminders from HelpSignal about onboarding, listing verification, reusable update links, status reminders, and service updates. These emails are not marketing emails.

Electronic signature name *

Signer title *

Signature date *

Availability is not guaranteed and can change. When a provider shares current status, HelpSignal labels it as provider-reported. Other listing details may come from public sources checked by HelpSignal. Call first when possible.