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

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

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.

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

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.

Check all that apply