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.