(407) 898-0110

1525 E. Robinson St. Orlando, FL 32801

Programs

Mental Health Connections

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We offer a free Mental Health Connections program for individuals seeking information for themselves, family, or friends. If you are in need of mental health services please contact us by calling our office at 407-898-0110 or by completing the form below. If you choose to complete the form, please detail your story in depth in the notes section so we have a full understanding of what we can research to best fit your needs. Our research process takes 1-2 business days. If you have an emergency need please highlight it in the form and utilize our Community Crisis Suicide Services page. 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

In light of the recent recommendations of self-quarantining for COVID-19, MHACF has provided this Online Services Document that outlines some providers in the community that are offering online counseling/psychiatry for those in the community looking for services they can access from home.

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:

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 Florida Hospital ER for any mental health services in the past few years?

Yes No Other Hospital

Have you ever been denied for Disability or SSI?:

Yes No Never Applied

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 Coverage:
*If you have a Medicaid HMO please indicate what type.

If you are uninsured do you need sliding scale services? :

Yes No

Would you like information about The Affordable Care Act? :

Yes No

Would you like information about Medicare / Medicaid? :

Yes No

Military Veteran?:

Yes 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?:

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)