Referral Form

If this is an emergency, dial 911.
Answer the questions below to provide the information to make a referral

Which of the following best describes the person making this referral:

Medical/Behavioral Healthcare Provider Family Member/Signficant Other Other Referral Source Self

Contact Information for Person Making Referral

First name

Last name

Preferred Contact Method:

Phone Email

Email Address:

Preferred Referral Confirmation Method:

Phone Email Text

Phone

Best Time To Contact

Relationship to person being referred:

-Select an option-AuntBrotherCase ManagerDrug Court RepresentativeDSS WorkerFatherJudgeMotherOtherPreventative WorkerProbation OfficerPsychiatristSelfSister

Additional Information:

Contact Information for Person Being Referred

First name

Last name

Gender

Female Male Other

Date of Birth

Address- Line 1

Address-Line 2

City:

State

New York

Zip Code:

Mobile Phone:

Home Phone:

Email Address:

Referral Information

*Is the person (Self Referral – Are you ) in crisis:

Yes No

Does the person require medication? (You will be asked for a list of medications by your admissions counselor):

Yes No

Types of Services Needed:

Mental Health Substance Use Both Other

Does the referred person meet any of the criteria below for priority admission status?:

Parents in Jeopardy of Losing their Children Servere Mental Health Domestic Violence Hospital/Facility Discharge

Additional Information Relating to Referral:

Currently Insured?

Yes No Unknown

Insurance Information:

Policy Holder:

Submit

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