Application for Mental Health Services -

Name

First

Last

Date of Birth

MM-DD-YYYY

Age

Client’s Contact: phone number

999-999-9999

Email address:

School:

Grade level:

Parent or Guardian’s Name:

First

Last

Relationship to client:

Address:

City:

Zip code:

Mental Health Issues Client is experiencing. (Please Check all that apply)

Current or Prior Mental Health issues such as Anxiety or Depression, etc..
Current or Prior Involvement with Department of Children & Families
Currently having issues with following rules and procedures at home or in school.
Current or Past Traumatic Stressors
Sibling of a Current individual involved in the Juvenile Justice System
Currently or Past involvement in self-harming activities such as, sexual promiscuity, cutting, vaping, and drinking alcohol.
Current or Prior Run-away or experiencing homelessness.
Current or Prior failure of several classes in school.
Current or Prior history of school interventions such as suspension, expulsion, excessive absenteeism

at at family

Household Income Requirements: Proof of household income: Persons in family or household and Poverty Guidelines For 2024

Checklist of documents, that must be attached to application. Client Eligibility 1. Broward County Resident (must have at least 1 of the following documents)

State-issued identification card with current address (with parent or guardian name)
Florida homestead exemption showing current address (with parent or guardian name)
Original Utility bill (with parent or guardian name)
Current Florida voter registration card (with parent or guardian name)
Bank statement (with parent or guardian name)
Vehicle Insurance and registration (with parent or guardian name)
Affidavit or Certification of Homelessness

2. Household Income guidelines (must have a least 1 of the following documents)

Wages and Tax statement (W-2 and/ or 1099)
Two (2) most recent consecutive pay stubs
Prior year’s 1040 Federal or state tax return
Proof of public assistance
Disability benefits letter (must contain first & last name, benefit amount and frequency of pay)
Unemployment benefits letter (must contain first & last name, benefit amount and duration

3. Clients and their families must be uninsured or underinsured and lack third- party insurance coverage (must have at 1 of the following documents)

Letter or statement of coverage denial from Medicaid, Medicare, or another insurer
Letter or statement from an insurance carrier that shows that you or your family members aren’t enrolled in or eligible for insurance coverage.
Letter or statement from an insurance carrier that shows that you or a family member are enrolled in an insurance program that does not cover or had limited coverage for services being applied for