NAMI-NYC Rapid Referral Form

Please provide information about the individual who is being referred - your client - in the first section, and information about the referring provider - you - in the second section.

Information about the person being referred

Their first name

Their last name

Their phone

Their email

If you do not have an email for your client, please use this format with your client's name: fakeclientname@email.com (e.g. fakeRoseSmith@email.com)

If referring from NYC Well, enter Call Report Number (CRN)

Please indicate the relationship of your client to the individual who is living with a mental health condition.

Please describe your selection of "Other Relationship"

Best time to call - check all that apply

MorningAfternoonEarly evening

Primary language - what they use most frequently to communicate with?

What language is their Primary Language?

I give permission to my healthcare or other service provider to give my name, contact information, and protected health information to NAMI-NYC. I understand that a NAMI-NYC Helpline volunteer or staff person will contact me about the free support and educational services that are available. I understand that my name, contact information and other information listed will not be disclosed or shared with any other entity unless authorization is obtained by me. I understand that I can revoke my permission at any time by contacting the referring provider named below. I give permission to NAMI-NYC to follow up with the provider named below.

Electronic signature

I consent
By checking this box, I, the provider making this referral, attest that I have received verbal consent from the individual being referred to make such referral.

Information about you, the referring provider

First name

Last name

Select your organization

Your program/department name

Your title

Your work phone

Your work email

What is your preferred contact method?

PhoneEmail

NAMI-NYC Program Descriptions

Education Classes
- NAMI Family-To-Family: For families, caregivers, and friends of adults with mental illness
- NAMI Peer-To-Peer: For people with a mental illness who wish to establish and maintain their wellness and recovery
- NAMI Basics: For parents and caregivers of children and adolescents to age 18 with behavioral or emotional issues, or mental health diagnoses
Support Groups: 40 traditional emotional support groups and social groups to build community, for both family members and adults with mental health challenges.
Family Mentor Match: Connect, via phone, experienced family members with family members whose loved one has been recently diagnosed or who are facing new mental health challenges.

Program(s) of Interest

Education ClassesSupport GroupsFamily Mentor MatchBasic information about NAMI-NYCCheck all that apply

Reason for referral / any comments?