Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Behavioral Issues with a child or teenager? Different varieties of therapy and different Approaches other than traditional mental health treatment? Community resources - Referrals? Other? Please List:

Psychotherapy Medication Management Psych Evaluation Targeted Case Management (Intensive or not) Single Injection Appointment (15 mins) PSR Therapy Substance Abuse Therapy Group Therapy Individual Therapy Children's / Teen Therapy Specialized Therapy - Please List : Drug Screens ( Court ordered or not - Hair - labs - mouth swab - urine) DNA Testing Couple's Therapy TBOS - PT - ST - OT - For Children/ Teens and Adults Recommendation Letters ( For employers - Court - Other Legal Instances - DCF - Must Commit to a 90 day period where you will see a therapist - get on the medications you need to - or get whichever other help you need in the community BEFORE the letter is signed and sent or given to you) General Education ( Things like : What mental health is - what certain diagnosis mean and can present in family and friends - the free options out there for help and resources for food and medical or legal help - Starting a community mental health center break down, and so much more!) Other

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past Currently Suicidal or Homicidal ( This includes thoughts - plans - attempts - threats ) Behavioral or Social Issues Current Depression or active mental health diagnoses? Currently Harmful Period to your peers and other providers Currently confused and unsure of what is going on Current and excessive Drug or Alcohol use - seeking help Past Alcohol or Drug use - Needing help Current and excessive Drug or Alcohol use - Unsure of what you are seeking Are you a mother? Parent? Guardian? Overwhelmed? Just need someone to talk to now and then , or help with connecting with resources in the community? Are you needing more intense services and resources? (Victim's advocate - Hoarding Help - Postpartum resources) Need help with Housing? Need help with SSI/SSD? Need help with Employment ? Resume - and Job Application help? Need help with Food or Household items?

SNAP/EBT/FOOD STAMPS : $ MEDICAID/ MEDICARE : $ WIC- WOMEN, INFANTS AND CHILDREN : $ FREE UBER RIDES - FREE BUS PASSES : $ FOOD DONATION PANTRIES AND SERVICES: $ TANF - CASH ASSISTANCE : $ UNEMPLOYMENT : $ HUD - PALM BEACH HOUSING AUTHORITY AND RELATED HOUSING RESOURCES : $ LOW INCOME : $ ELECTRICITY - WATER - HEATER - AC - ETC ASSISTANCE : $ PHONE LINE ASSISTANCE - CELL PHONE ASSISTANCE : $ SCHOOL LUNCH ASSISTANCE : $ CHILD SUPPORT : $ RESTITUTION : $ OTHER COURT FUNDS : $ SCHOOL BUS TRANSIT FUNDS FOR SPECIAL NEEDS AND AREAS THAT DON'T HAVE PBCSD BUS STOP PICKUPS OR DROP OFFS : $ MASTER TRUST FUNDS FROM THE STATE : $ BENEFITS FROM OUT OF STATE OF OUT OF COUNTRY: $ BENEFITS FROM A TRIBAL GROUP OR OTHER PROTECTED GROUP : $ VETERANS BENEFITS : $ PRESCRIPTION DRUG BENEFITS : $ ANY OTHER BENEFITS - FUNDS - ASSISTANCE THAT YOU ARE GETTING : $