CASES General Referral Form To make a referral to the Nathaniel Clinic, please visit nathanielclinic.org. To make a referral to CASES HH+ Care Management, please use this link: https://forms.office.com/Pages/ResponsePage.aspx?id=C4MZGb_JsE2_YVH0-J5oGbbNR8OGst9KmrfIY3Wt_f1URFY1NlVLNE4xMVgySFpJQlI0RUE1VUo3TSQlQCN0PWcuYour Name(Required) Email(Required) PhoneWho are you referring? Myself Someone else Age(Required) Name of person being referred(Required) Age of person being referred(Required) Relationship to person being referred(Required) Borough of residence(Required) The Bronx Brooklyn Manhattan Queens Staten Island Do you live in Coney Island? Yes No Do you live in Harlem? Yes No Criminal legal system involvement Incarcerated Probation Parole Arrested within the last year None Prefer not to say Was your/the person being referred's arrest for a felony or a misdemeanor? (if applicable) Felony Misdemeanor Not sure Not applicable Have you/the person being referred been diagnosed with a serious mental illness? Yes No Unsure What type of programs or services are you seeking? Youth development (after-school programming, mentoring, GED/HSE test prep, employment opportunities, etc.) Family Therapy Comments/questions
