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 select...
My client has a mental health condition
My client is a Spouse/Partner
My client is a Parent
My client is an Adult Child
My client is a Sibling
My client is a Friend
Other
Please describe your selection of "Other Relationship"
Best time to call - check all that apply
Morning
Afternoon
Early evening
Primary language
- what they use
most frequently
to communicate with?
Please select...
English
Spanish
Cantonese
Mandarin
Russian
Other
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
Please select...
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 organization
Your program/department name
Your title
Your work phone
Your work email
What is your preferred contact method?
Phone
Email
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 Classes
Support Groups
Family Mentor Match
Basic information about NAMI-NYC
Check all that apply
Reason for referral / any comments?
Contact Information