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 virtual counseling option. If you prefer in-person services for your child, we recommend to contact your child's school counselor or social worker to discuss if a BRAVE school based referral is appropriate and applicable. Please note that a Community Health Associate will contact you within 48 business hours of the referral being submitted.
Who is this referral for?
Please Select
My Child
School Staff
Please select the county your child resides in
*
Please Select
Clay County
Columbia County
Lake County
Nassau County
Miami-Dade County
Okaloosa County
Putnam County
St. Johns County
Volusia County
Other
Please select the county you reside in
*
Please Select
Clay County
Columbia County
Nassau County
Lake County
Miami-Dade County
Okaloosa County
Putnam County
St. Johns County
Volusia County
Other
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Gender
*
Please Select
Male
Female
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming (i.e. not exclusively male or female)
Child's Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Please select the most appropriate option
*
Please Select
My child is homeschooled
My child attends a private school
My child attends a public school
My child participates in Kennedy Kids
N/A
Individual Seeking Services or Parent/ Legal Guardian's Name
*
First Name
Last Name
Individual Seeking Services or Parent/ Legal Guardian's Date of Birth
*
-
Month
-
Day
Year
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
City
State / Province
Postal / Zip Code
Why are you seeking mental health services? (select all that apply)
*
Anxiety/stress
Depression/sadness
Grief/loss
Trauma
Relationship issues
Substance use/abuse
Other
How did you learn about BRAVE?
*
Signature of the Individual or Guardian (typed name)
Submit
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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