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Referral Form

(Please compete form for one individual at a time)
If this is an immediate crisis please call 211 or 911.
I consent to allow MHACF to release my Contact Information to an insurance navigator or mental health provider:
Name of individual needing services:
Name of individual filling out this form:
Add Email to distribution?:
*Please note that we will only contact the person filling out this form.
Address:
*Please note that this is the location we will reference to find services closest to you.
Have you filled out a previous referral?:
Have you ever been diagnosed?:
Do you identify as LGBTQ+?:
Have you visited a Baker Act Receiving Facility for any mental health services in the past few years?:
Have you ever been denied for Disability or SSI?:
Do you currently have active Disability Benefits?:
Do you have a primary care doctor?:
Are you currently taking any medications?:
Are you interested in Faith-based services?:
Indicate specific Faith; if any
Services Being Requested:
*If you have a Medicaid HMO, please indicate what type.
If you are uninsured, would you be interested in sliding scale services? (cost can adjusted based on an application for reduced fee):
Would you like information about The Affordable Care Act? :
Would you like information about applying for Medicare/ Medicaid/ Kidcare? :
Military Veteran? :
Currently Employed?:
Is this request related to the COVID-19 Pandemic?:
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.
How would you prefer to be contacted?:
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)
Please be aware that email content is not confidential. If you would like to ensure complete confidentiality, please call us for referrals.

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