Community Mental Health Resource Directory Template The following template provides an overall guide to key information for inclusion in a community resource directory: 1. Type of provider (Please check one.) Mental health professional Please specify type (eg, psychiatrist, psychologist, developmental and behavioral pediatrician, adolescent medicine specialist, licensed clinical social worker): _______________________________________________________ Community mental health agency Hospital Local health department Other, please specify: _____________________________________________ 2. Age groups served (Please check all that apply.) Birth to 11 months 1 to 4 years 5 to 10 years 11 to 21 years Adults 3. Types of evidence-based child and adolescent psychosocial interventions1 provided to children and their families (Please check all that apply.) Cognitive behavioral therapy Behavior therapy Parent training Educational support Interpersonal therapy Family therapy Applied behavioral analysis Other, please specify: _____________________________________________ 4. Any programs provided to children and their families (Please check all that apply.) Consultation to child-serving organizations and providers (eg, early childhood programs, primary care clinicians) Home visiting Parenting education Respite care Outpatient treatment Day treatment Others, please specify:2 ___________________________________________ 5. Payment type accepted (Please check all that apply.) Private insurance (List all that are applicable.) Medicaid State Children’s Health Insurance Program (SCHIP) Self-pay Sliding scale Other, please specify: _____________________________________________ 6. Hours of operation (Please list.) 7. Office location(s) (Please list.) 8. Any targeted services provided (eg, multilingual staff, interpreters, outreach to underserved families) 9. Other pertinent information The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit. Copyright © 2010 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes.