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NAMI-NYC Rapid Referral Form
NAMI-NYC Rapid Referral Form
Information about the person being referred
*First Name:
*Last Name:
*Phone number of the person being referred:
*Email address of the person being referred:
IF YOU DON’T HAVE an email for your client, please use this format: fakeclientname@email.com (eg. fakeRoseSmith@email.com)
If referring from NYC Well – please enter the Call Report Number (CRN)
*Please indicate the relationship of your client to the individual who is living with a mental health condition (please check all that apply)
The person I’m referring has a mental health condition
Spouse/Partner
Parent
Adult Child
Sibling
Friend
Other
If Other, please list:
*Best time to call
Morning
Afternoon
Early Evening
*Age of Individual Referred:
*Primary Language:
–None–
English
Spanish
Chinese (Mandarin, Cantonese)
Russian
Hindi
Portuguese
Bengali
Other
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
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 the referring provider
*First Name
*Last Name
*Select your organization from the dropdown
–None–
Abbott House
Academy of Medical and Public Health Services (AMPHS)
ACMH
ACS (Administration for Children’s Services)
Alliance for Positive Change
Anthem Blue Cross Blue Shield
Arab-American Family Support Center
Argus Community, Inc
BronxCare Health System
CARES NYC
Center for Court Innovation
Children’s Aid
Cityblock NYC
Community Healthcare Network
CUCS (Center for Urban Community Services)
Elmhurst Hospital / NYC H+H
Empire Blue Cross Blue Shield
Forestdale Inc
Fountain House
Goodwill Industries NY/NJ
Gracie Square Hospital
Graham Windham
Healthfirst
HeartShare St. Vincent’s Services
Henry Street Settlement
Housing Works
Howard Beach Medical Office
Icahn School of Medicine at Mount Sinai
Immigrant Justice Corps
ICL (Institute for Community Living, Inc)
IFH (Institute for Family Health)
JCCA (Jewish Child Care Association)
Jewish Board
Kings County Hospital / NYC H+H
LESFU (Lower East Side Family Union)
Mental Health Providers of Western Queens
Metropolitan Hospital / NYC H+H
Montefiore Medical Center
Mount Sinai Beth Israel
New York City Children’s Center
New York Foundling
NYP (New York Presbyterian Hospital)
NYC Children’s Services
NYC H+H/ Community Care
NYC Well / Vibrant Emotional Health
NYU Langone Health
Paul J. Cooper Center for Human Services, Inc
Pratt Institute
Project Renewal
PRFI (Puerto Rican Family Institute)
Queens Hospital / NYC H+H
Ryan Health
Safe Horizon
SCAN-Harbor
SCO Family of Services
Seamen’s Society for Children and Families
Seventh-day Adventist Church
Sheltering Arms Children and Family Services
Tribeca Pediatrics
TSINY (Transitional Services for New York, Inc.)
Valera Health
Other referring org
*Please fill in your Program/Department
*Provider’s Title
*Provider’s Phone
*Provider’s Email
Program of Interest Descriptions
Education Classes
Family-To-Family: For families, caregivers, and friends of adults with mental illness
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 with behavioral or emotional issues, or mental health diagnoses
Support Groups: 30 monthly traditional emotional support groups, and socialization groups to build community, for both family members and adults with mental health challenges.
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.
Please note that all of our programs are being held remotely via Zoom or telephone until further notice.
*Program of Interest (please check all that apply)
Education Classes
Support Groups
Mentor Match
Basic Information about NAMI-NYC
*Reason for Referral/Comments:
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