Mental Health Association of Central Florida

Mental Health Connections

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.

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

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
Services Being Requested:
Addictions Counseling
Advocacy / Reporting Information / Education
Employment Assistance
Financial Services
Concierge Services
Transportation
Volunteer Opportunities
Assisted Living Facility
Case Management
Couples Counseling
Domestic Violence
Group Counseling
Group Home
Homeless Services
Individual Counseling
Intensive Outpatient
Long Term Residential
Medicare / Medicaid Information
Marriage Counseling
Partial Hospitalization
Psychiatric Services (Explain Below)
Short Term Residential
Family Counseling
Detox
Other Substance Abuse (Explain Below)
Other Counseling (Explain Below)
Support Group(s) (Explain Below)
Court Ordered Evaluation
Short Term Residential
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
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?:
 Phone   Email   Both


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)