BRAVE Community Referral

BRAVE Community Referral

This program serves youth 18 and below and/or school staff in BRAVE counties we currently serve. By submitting this referral please know that we recently changed our BRAVE Community Referral process to match your child with a provider that accepts your insurance. Majority of our partnered agencies provide Cognitive Behavioral Therapy. If we cannot find a provider that fits your needs in our network, we will assist with sending you resource options. Please note that a Community Health Associate will contact you within 48 business hours of the referral being submitted. Thank you for your understanding.
Who is this referral for?
Please note a recent change with resources now available through the BRAVE Community Referral. Due to recent funding changes, we are now able to provide the following for school staff to utilize.

Betterhelp: 30% off link for your first month of individual or couples therapy. Please click here to redeem this offer.

Togetherall: A Free online peer to peer support available 24 hours a day and 7 days a week. Please click here to learn more and redeem this offer.

Other Parents Like Me: A Free online peer to peer support available through virtual groups offered at various days and times. Please click here to learn more and redeeem this offer.

By submitting the form below, a BRAVE CHA will contact you in order to discuss these resources further and assist with next steps.
Please select the county your child resides in*
Does your child have Health Insurance?*
Name of Insurance Company
Insurance ID Number
Please select the county you reside in
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Child's Race*
Please select the most appropriate option*
Individual Seeking Services or Parent/ Legal Guardian's Name*

First NameLast Name
Individual Seeking Services or Parent/ Legal Guardian's Date of Birth*

MonthDayYear
Date
Individual Seeking Services or Parent/ Legal Guardian Phone Number*
Individual Seeking Services or Parent/ Legal Guardian Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Why are you seeking mental health services? (select all that apply)*

Anxiety/stressDepression/sadnessGrief/lossTraumaRelationship issuesSubstance use/abuseOther
How did you learn about BRAVE?
How did you learn about BRAVE?*
If other was selected, please share how you learned about BRAVE:
Signature of the Individual or Guardian (typed name)
I agree that this agreement may be electronically signed. I agree that the electronic signature appearing on this agreement is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. I understand that •I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will not be affected. I may also request a copy of this consent after I sign it. •This consent form expires in seven (7) years. I have the right to revoke this consent at any time by writing to the Agency, except to the extent that the agency has acted in reliance on it. Past information I previously consented to release will not be retrieved from agencies that received that information. I understand that my revocation must be in writing. •The Agency has posted a Notice of Privacy Practices, and I may request a paper copy of the Notice from the Agency. I acknowledge that I have been given an opportunity to read and/or request a copy of the Notice and that I have read the Notice. The Notice describes ways in which my personal information may be used and disclosed within and outside of the Agency. Its terms may change and I may obtain a copy of the Notice by writing to: CCIN SERVICEPOINT c/o Flagler Health+ Care Connect, 400 Health park, Blvd. St. Augustine, FL 32086. •I understand that neither the Agency, nor the CCIN, can control how another Participant will use or disclose my information that it receives under this consent. It is possible that the other agency will disclose my information to others, and that the disclosed information may no longer be protected by federal privacy regulations.
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