Referral Form

BEFORE COMPLETING THIS FORM PLEASE CALL 212-787-7120 X514 OR EMAIL [email protected] TO REQUEST INFORMATION ON CLINIC AVAILABILITY. All form data is encrypted and submitted securely over an SSL (HTTPS) connection. Please check your browser’s URL bar for the appearance of “https” or look for the “lock” icon for confirmation. Fields marked with an asterisk (*) are required. This form works best using Chrome browser

Clinic(Required)

(Individual & Group therapy, Medication management)

Yes

PROS(Required)

(Psych rehab services for persons with experience of SPMI. Primarily group-based. Medicaid only. *Referrals must have a recent psychosocial and psychiatric evaluation attached)

Yes

Bereavement Support(Required)

(Peer-facilitated support groups for adults who have lost a loved one or spouse)

Yes

Does client require services at a specific location?(Required)

Yes

Select Satellite/Site(Required)

Preferred treatment setting

In person

Zoom/Telehealth

Click here if referral is from inpatient setting, rehab, nursing home, prison, mobile crisis unit, emergency department(Required)

Yes

Homebound(Required)

Yes

Monolingual(Required)

Yes

Language(Required)

Referrer Name(Required)

Title

Agency(Required)

Relationship to Client

Client Name(Required)

Client Telephone(Required)

Client Email

Call First(Required)

Client

Referrer

Other

Date of Referral(Required)

Medicare ID(Required)

Write “N/A” if client does not have Medicare coverage.

Medicaid ID(Required)

Write “N/A” if client does not have Medicare coverage.

Other Insurance(Required)

Write “N/A” if client does not have Medicare coverage.

Social Security #(Required)

Marital Status(Required)

Address(Required)

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Referrer Telephone(Required)

DOB(Required)

Emergency Contact Name(Required)

Emergency Contact Relationship(Required)

Emergency Contact Phone Number(Required)

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Phone Number

Lives(Required)

Alone

With another individual

Name of Person Living with

Name of Person Living with(Required)

Relationship of Person Living with(Required)

Phone Number of Person Living with(Required)

Who Can Help Engage in Treatment?

Name of Person Helping in Treatment

Relationship of Person Helping in Treatment

Phone Number of Person Helping in Treatment

Home Safety

Are there firearms in the home?(Required)

Yes

Unknown

Are there other weapons in the home?(Required)

Yes

Unknown

Other Mental Health Providers

Are Other Mental Health Providers Involved?(Required)

Yes

Who is Expected to Prescribe Psychotropic Medications?(Required)

SPOP

Outside Psychiatrist

Primary Care MD

Prescriber Name(Required)

Prescriber Specialty/Clinic(Required)

Prescriber Address(Required)

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Prescriber Phone Number(Required)

Other Mental Health Provider Name

Other Mental Health Provider Specialty/Clinic

Other Mental Health Provider Address

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Other Mental Health Provider Telephone

Physician/Hospital/Clinic Information

How many Physician/Hospital/Clinic fields to fill out?(Required)

Physician/Hospital/Clinic 1

Name 1(Required)

Specialty/Clinic 1(Required)

Phone Number 1(Required)

Address 1

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Physician/Hospital/Clinic 2

Name 2(Required)

Specialty/Clinic 2(Required)

Phone Number 2(Required)

Address 2

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Physician/Hospital/Clinic 3

Name 3(Required)

Specialty/Clinic 3(Required)

Phone Number 3(Required)

Address 3

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Homecare Information

Has Homecare?(Required)

Yes

Agency(Required)

Phone Number(Required)

Contact Person(Required)

Name of Home Attendant(Required)

Days Per Week(Required)

Please enter a number from 1 to 7.

Hours Per Day(Required)

Please enter a number from 1 to 24.

Other Organizations Involved

Are there other organizations involved?(Required)

Yes

Other Organizations 1 Name

Other Organizations 1 Address

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Other Organizations 1 Phone Number

Other Organizations 2 Name

Other Organizations 2 Address

All fields for this address are required. If there is no suite/apartment, please enter “none”.

Other Organizations 2 Phone Number

History

Reason for Referral(Required)

(Include history of problem, symptoms, and current situation)

Psychiatric History(Required)

(e.g. prior treatment, hospitalizations, suicide, violence, substance abuse)

Medical Status(Required)

(e.g. current medical status, recent hospitalizations and surgery)

Medications

Medication

Dosage

Please list all medications and dosage. Click + to add additional rows.

Supportive Clinical Documentation

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 100 MB.

Please attach supportive clinical documentation and records here. File types allowed: jpg, gif, png, pdf, doc.

Social Network

List Social Network

(e.g. family, friends, community involvement, religious affiliations, activities)

Intake Completed By

Signature(Required)

Please draw your signature using your mouse.

Print Name

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