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

Apt. Number

City

State

ZIP Code

Phone Number

Best time to call

Are you a Pinellas County Resident?

How many minor children do you have in your custody and in your household?:

Are you or another person in the household pregnant?

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

Is there any income in the household right now?

Will you be receiving new income in the next 30 days, and will you have documented proof of it?

Will you be able to pay all your expenses next month?

Have you previously worked with a PEMHS/Eleos or Gulf Coast System Navigator?

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?