Apply For Assistance – Eleos Wellness

FSI Connect Contact Form

Fill out the contact form and an FSI Connect staff member will contact you within two business days.

Date

First Name

Last Name

Date of Birth

Address

Street Address

Address Line 2

City

State

ZIP Code

Phone Number

Best time to call

Are you a Pinellas County Resident?

Number of minor children living with you

Do you already have a case manager / professional (SunCoast, Directions, CPI, Healthy Families) to help you coordinate social services?

Do you have income or will you be receiving new income in the next 30 days and will you be able to pay all your expenses next month?

Will you have documented proof of your income within the next 30 days?

Have you previously worked with a PEMHS or GulfCoast System Navigator?

Are you pregnant?

What services are you seeking?

Why do you require services and what caused you to fall behind?

In an effort to assist you, can we share your personal information with assigned System Navigator/ Community Partners?