(407) 898-0110

1525 E. Robinson St. Orlando, FL 32801

Programs

Mental Health Connections

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A free information and referral resource for individuals seeking mental health information for themselves, family, or friends. With a database of 2,500 mental health, addiction treatment and community care providers, hospitals and treatment facilities and consumer run organizations that deliver services in Orange, Osceola, Seminole, Lake, Brevard and Volusia counties. Over 4,200 referrals are made annually to individuals and families in need of mental health resources. Callers receive resources in 24-48 hours and a follow-up check in on the Connection. Over 1,000 volunteers have dedicated their time in the last 5 years. To create a referral inquiry complete the form below or call our office at 407-898-0110. To join as a Connections resource email Alan at ABruns@mhacf.org.

If you are experiencing a mental health emergency need please highlight it in the form and/or utilize our Community Crisis Suicide Services page for information on hotlines and local mental health receiving facilities. For brief definitions of the services below please refer to this Description of Services Document

If you are looking for immediate resources available for mental health, whether that be an immediate person to talk to in a crisis situation or just an additional support to talk things through with a qualified individual, those options are in this Immediate Resources Document

Referral Form (Please compete form for one individual at a time):

If this is an immediate crisis please call 211 or 911.

If you are currently safe but you consider this request to be urgent, please indicate which urgent concern best fits:

I consent to allow MHACF to release my Contact Information to an insurance navigator or mental health provider:

Yes No

Name of individual needing services:

First:

Last:

Name of individual filling out this form:

First:

Last:

Phone:

Email:

Add Email to distribution?:

Yes No

*Please note that we will only contact the person filling out this form.

Relationship to individual needing services:

Address:

City:

State:

Zip:

County:

*Please note that this is the location we will reference to find services closest to you.

How far are you willing to travel for services?:

Have you filled out a previous referral?:

Yes No

How did you hear about us?:

Have you ever been diagnosed?:

Yes No Unsure N/A

Age:

Race:

Gender:

Have you visited a Baker Act Receiving Facility for any mental health services in the past few years?

Yes No

Have you ever been denied for Disability or SSI?:

Yes, Applied & Was Denied No, Applied & Was Approved No, Never Applied

Do you currently have active Disability Benefits? :

Yes No

Do you have a primary care doctor?:

Yes No Would Like A Referral

Are you currently taking any medications?:

Yes No N/A

Are you a current college student?:

Yes No

Are you interested in Faith-based services?:

Yes No Open to it

Indicate specific Faith; if any

Current Insurance Plan and Provider:
*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) :

Yes No

Would you like information about The Affordable Care Act? :

Yes No

Would you like information about applying for Medicare/ Medicaid/ Kidcare? :

Yes No

Military Veteran?:

Yes, and I qualify for Tricare
Yes, but I do not qualify for benefits
No

Currently Employed?:

Yes No

Is this request related to the COVID-19 Pandemic?:

Yes No

Notes/Additional Info:

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)

Yes, I prefer it
Maybe, I’m open to it
No, I am not interested

Please be aware that email content is not confidential. If you would like to ensure complete confidentiality, please call us for referrals.

“A COPY OF THE OFFICIAL REGISTRATION & FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.” (Registration #CH 1245)