Please enter your program data for a chance to win an iPod Nano!

The drawing for the iPod will be held on January 14, 2008.
Fields with an asterisk* are required to be eligible for the drawing.


This information is being collected by The Woman's Heart, a non-profit company providing recovery support in Wyoming. Information collected is being compiled into a database for state-wide use. The information will be made available for public web-based searches, and will become part of a directory used for referral systems in the state. If adopted across the state, the database will make it easier for everyone to know about available services. Any other group can use the database for their own needs; for example, you can create directories of services to use with your clients. We provide, at no cost, a search box that can be put onto any website to locate information from this database. If you don't have a website, we may be able to provide you with one. Your agency gains exposure to state agencies and other programs through the database. You can maintain your own information online, logging in to update hours, fees, program description, etc. Information on how to access your data and update it will be sent to you.

Please provide contact information for your agency or service:
Program Name*:
AKA:
website address:
Agency:
Person in charge:
Person in charge title:
Hours of operation:
Phone 1*:
Phone1 notes (e.g. after hours phone, fax, etc.):
Phone 2:
Phone 2 notes:
Phone 3:
Phone 3 notes:
Address 1 info (e.g. Office Address, Mail Address):
Address 1 (street)*:
Address 1 (unit, etc.):
City 1*:
Zip 1*:
County 1*:
Address 2 info
(if you have a second address,
e.g. mailing address):
Address 2:
Address 2:
City 2:
Zip 2:
County 1*:
Please provide your contact information:
Name of Contact 1*:
Name of Contact 1 email*:
Name of Contact 2:
Name of Contact 2 email:
Please tell us about the population you serve:
Minimum age:
Maximum age:
Gender:
Short description (255 characters max):
Long description (any length):
Keywords--provide words
you want clients to be able to
use to find you in a search:
Fees or fee structure:
Intake process:
Languages:
Eligibility requirements:




Any questions, please contact:
     Stephaine Moles
     The Woman's Heart
     120 East 2nd Street
     Casper, WY 82601
     307-224-4464 office
     307-258-1709 cell
     800-934-0249 fax
     Email: stephanie@thewomansheart.org