Information & Referral Line Data Base Application

Organization: Specialty: (EMDR, Grief, Trauma, DV, Address: Areas Served: Contact person: Services Offered: (check as many as apply)
MENTAL HEALTH
Individual Counseling -Adults Individual type accepted: PaymentCounseling-Children victims of crime, etc.)

Tel. #:

Website: Language(s): Tel.#:

ALCOHOL OR DRUG TRTMT
Individual Counseling-Adults Individual Counseling-Children Insurance MediCal Sliding

Email addr:
MEDICAL HEALTH

Explain:________________________ Medication-Free MEDICAL HEALTH Medication-Discount Medical Evaluation Medical Equipment AIDS Explain:________________________ & HIV Services Programs/Services for expectant Explain: mothers Medication-Free Transportation to Medical appts. Group Counseling-Children Group Counseling-Youth Medication-Discount Mental Health Day Trtmt-Adult AOD Day Trtmt-Adult Eye Care Support Groups Support Groups Medical Equipment Mental Health Day Trtmt-Youth AOD Day Trtmt-Youth Hearing Care Explain: Explain: Explain: Psychoanalysis-Adults Detox Urgent Care Mental Health Res.Trtmt-Adult AOD Res Trtmt-Adult Programs/Services for expectant mothers Explain:_______________________ Psychoanalysis-Children Emergency Medical Care Mental Health AOD Res Trtmt-Youth Transportation Care Psychiatric Hospital Res Trtmt-Youth Hospice to Medical appts. Mental Health Day Trtmt-Adult AOD Day Trtmt-Adult Eye Care Mental Health Day AOD Day Trtmt-Youth Hearing Care OTHER DENTAL SERVICESTrtmt-Youth VETERANS/DISBALED SERV. Psychoanalysis-Adults Urgent Care Childrens Dental Services Detox Resources for Disabled Employment Services Psychoanalysis-Children Emergency Medical Care Family Dental Explain: Vets Resources for Food or Clothing Psychiatric Hospital Hospice Care Violence Shelter Housing for Vets or Disabled Domestic Domestic Violence Counseling DENTAL SERVICES VETERANS/DISBALED OTHER Ex-Offender Dental Mental Health Services for Vets Permanent/Transitional Housing SERV. Resources for Disabled Support Services Temporary Shelter/Rental Asst. Childrens Dental Services Employment Services Explain:________________________ Explain:________________________ Family Dental Resources for Vets Food or Clothing Foster Family Services Housing for Vets or Disabled Domestic Violence Shelter Kinship Care Counseling CRISIS & INFO LINE EDUCATIONAL SERVICES Domestic Violence Hot lineEx-Offender Dental Mental Health Services for Vets Preschool/Childcare Respite Care Permanent/Transitional Housing Suicide Prevention & Crisis Line IEP/Special Ed Transportation Support Services Temporary Shelter/Rental Asst. Advocacy Service Explain: After School Programs Faith-based Explain: Law Enforcement Parenting Classes Legal Services Foster Family Services Mental Health Emergency Anger Management Classes Gay/Lesbian Services Kinship Care CRISIS & INFO LINE EDUCATIONAL SERVICES Ex Offender Services Suicide Prevention & Crisis Line Preschool/Childcare Respite Care Advocacy Service IEP/Special Ed Transportation Other (explain): Law Enforcement After School Programs Faith-based Mental Health Emergency Parenting Classes Legal Services Submitted by:_________________________________________________________________ Date:__________________________________________ Anger Management Classes Gay/Lesbian Services Ex Offender Services Group Counseling-Adults GroupMENTAL HEALTH Counseling-Children Individual Support Groups Counseling -Adults Explain:_____________________ Individual Counseling-Children Mental Health Res.Trtmt-Adult Mental Health Res Trtmt-Youth Group Counseling-Adults Group Counseling-Adults ALCOHOL OR DRUG Group Counseling-Youth TRTMT Individual Counseling-Adults Support Groups Explain: Counseling-Children Individual_______________________ AOD Res Trtmt-Adult Group Counseling-Adults AOD Res Trtmt-Youth

Scale

AIDS & HIV Services Cash/Check/M.O.

Medical Evaluation

Other (explain): Completed By:

Building Bridges Together is a dept. of the Families Forward Program of Mental Health Systems, Inc. & is funded by the County of San Diego. BBT reserves the right to final determination of any and all information included in its database and how it is dispersed to the public.

Date:

Building Bridges Together is a dept. of the Families Forward Program of Mental Health Systems, Inc. & is funded by the County of San Diego. BBT reserves the right to final determination of any and all information included in its database and how it is dispersed to the public.