Referral to Bronx Nathaniel Clinic

The Bronx Nathaniel Clinic is an approved Office of Mental Health article 31 clinic that provides mental health services in the South Bronx. Our clinic specializes in treating individuals who have been involved in the criminal justice system. We help justice involved people and other community members heal from trauma and improve emotional and physical health.

The Bronx Nathaniel Clinic provides a comprehensive array of outpatient services for individuals ages 13 and over with mental health disorders. These services include individual/group/family psychotherapy, medication management, crisis intervention, case management, and peer support services.

The clinic cannot accept the following types of referrals at this time:

1. Individuals whose only mental health diagnosis is related to substance use
2. Individuals whose only mental health diagnosis is related to a neurodevelopmental disorder (e.g., autism, intellectual disability, learning disability)
3. Referral only for the completion of forms related to entitlements (e.g., 2010e application, SSI application)
4. Referral for people who do not speak fluent English and do not want to utilize interpreter services

The clinic accepts Medicare, Medicaid, some commercial insurance plans, and is a participant in Medicaid Managed Care networks. For more information, please call (347) 848-1000 or email bronxmedicalschedulersnc@cases.org

Choose the level of service(Required)

1. Routine (Persons already receiving services or has been referred from CLS provider, health provider, or community referral that may be benefit from mental health services)

2. Urgent (Risk of decompensation due to lapse in prescription/long-acting injectables, suicidal ideation with no plan, active substance use risk )

3. Crisis (Suicide attempt, decompensation, suicidal ideation with means and plan)

Date of referral(Required)

First Name(Required)

Last Name(Required)

What is your current gender identity?(Required)

Identifies as Male

Identifies as Female

Female-to-Male (FTM)/Transgender Male/Trans Man

Male-to-Female (MTF)/Transgender Female/Trans Woman

Genderqueer, neither exclusively male nor female

Additional gender category or other, please specify

Choose not to disclose

Sexual Orientation

Lesbian, gay, or homosexual

Straight or heterosexual

Bisexual

Something else, please describe

Don’t know

Choose not to disclose

Describe Sexual Orientation

Date of Birth(Required)

Client/Contact Phone Number(Required)

Client Phone Number Type(Required)

Cell Phone

Home

Other

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Race(Required)

Asian

Black or African American

White or Caucasian

Native American

Multiracial

Native Hawaiian or Other Pacific Islander

Ethnicity(Required)

Non-Hispanic

Hispanic

Primary Language(Required)

English

Spanish

Other

Military Status

Active

Inactive

None

Reason seeking service(Required)

Is client between 13 and 17 years old?(Required)

Yes

Parent/Guardian Name(Required)

Parent/Guardian Phone Number(Required)

Parent/Guardian Email Address(Required)

Insurance Information

We are in-network with the following insurances: Medicaid, Medicare, Affinity, Amerigroup, AmidaCare, MetroPlus, Emblem, Fidelis, HealthFirst, HIP, GHI, United HealthCare, Wellcare, VNS Choice.

Social Security Number

This information is used for insurance verification.

Medicaid ID Number(Required)

Medicare ID Number

Commercial Insurance Plan Name

Commercial Insurance Plan Member ID

Referral Source(Required)

Self

CASES Program

Outside Agency

How did you hear about the Nathaniel Clinic?(Required)

Referring Program (CASES)(Required)

Referral Source - Contact Name(Required)

(first and last name of person making the referral)

Referral Source - Phone Number(Required)

Referral Source - Email Address(Required)

NYSID of person being referred(Required)

Client ID

e.g., AWARDS ID or Salesforce PCID for CASES Programs)

Please send supporting documentation for this referral (e.g., hospital discharge summary, medication list, previous psychiatric/psychosocial assessments) via email (medicalschedulersnc@cases.org) or fax (718-355-8985). If you anticipate asking the Nathaniel Clinic for health-related information such as written or verbal information about your client’s attendance, diagnosis, or progress, please send a completed HIPAA consent form such as OMH 11(c) via email (medicalschedulersnc@cases.org) or fax (718-355-8985). Your client must specifically consent to the Nathaniel Clinic's release of mental health information, alcohol/drug treatment information, and HIV/AIDS information. OMH 11(c) is available at: https://omh.ny.gov/omhweb/hipaa/manual/appendix3.pdf

Referral Source - Agency Name(Required)

Is this referral from a criminal justice agency?

Yes

Is this referral for a client who is being discharged from an inpatient psychiatric hospital?

Yes

Anticipated Hospital Discharge Date(Required)

Please upload supporting documentation for this referral (e.g., hospital discharge summary, medication list, previous psychiatric/psychosocial assessments, documentation of most recent long-acting injection administration date) below. If you are unable to upload, please send documentation via email (bronxmedicalschedulersnc@cases.org) or fax (718-576-1364).

If you anticipate asking the Nathaniel Clinic for health-related information such as written or verbal information about your client’s attendance, diagnosis, or progress, please also upload a completed HIPAA consent form such as OMH 11(c). If you are unable to upload this form, please send it via email (bronxmedicalschedulersnc@cases.org) or fax (718-576-1364). Your client must specifically consent to the Nathaniel Clinic's release of mental health information, alcohol/drug treatment information, and HIV/AIDS information.

OMH 11(c) is available at: https://omh.ny.gov/omhweb/hipaa/manual/appendix3.pdf

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