Referral Form

(Please complete form for one individual at a time)
If this is an immediate crisis please call the 988 Suicide & Crisis Lifeline
I consent to allow MHACF to release my Contact Information to an insurance navigator or mental health provider:(Required)
Name of individual filling out this form:(Required)
Are you their parent/guardian?(Required)
Have you filled out a previous referral?:(Required)
How would you prefer to be contacted?:(Required)
Can we leave a voicemail?(Required)
Add Email to distribution?:(Required)
*Please note that we will only contact the person filling out this form.
Name of individual needing services:(Required)
Address:(Required)
*Please note that this is the location we will reference to find services closest to you.
If not, then enter "N/A"
Do you identify as LGBTQ+?:(Required)
Have you ever been diagnosed?:(Required)
Have you visited a Baker Act Receiving Facility for any mental health services in the past few years?:(Required)
Have you ever been denied for Disability or SSI?:(Required)
Do you currently have active Disability Benefits?:(Required)
Do you have a primary care doctor?:(Required)
Are you currently taking any medications?:(Required)
Is the person needing services a college student?(Required)
If not, then enter "N/A"
Are you interested in Faith-based services?:(Required)
Indicate specific Faith; if any
*If you have a Medicaid HMO, please indicate what type.
Current Insurance Provider offered through:(Required)
If you are uninsured, would you be interested in sliding scale services? (cost can adjusted based on an application for reduced fee):(Required)
Military Veteran? :(Required)
Currently Employed?:(Required)
Would you like information about The Affordable Care Act? :(Required)
Would you like information about applying for Medicare/ Medicaid/ Kidcare? :(Required)
Is this request related to the COVID-19 Pandemic?:(Required)
Due to COVID-19, service delivery has changed. Are you open to seeing a provider virtually? (This would require a computer or phone with camera and internet access)(Required)
Do you currently use tobacco, vape or use other nicotine products? :(Required)
Are you interested in quitting?:(Required)
Can we refer you to some local experts who can help you quit and provide you with free nicotine gum or patches?:(Required)
MM slash DD slash YYYY
May I refer you to free services offered by Tobacco Free Florida to help you quit? (If you agree, someone from the Area Health Education Center will give you a call and get you registered. )(Required)
If yes, would you like to attend
Would you like to speak with a Quit Coach over the phone?
Services Being Requested:(Required)
If we need clarification on certain items one of our Mental Health Connections Specialists will reach out to you so please make sure any contact information is accurate.
Please be aware that email content is not confidential. If you would like to ensure complete confidentiality, please call us for referrals.