Referral to CASES OnTrackNY Program The survey will take approximately 6 minutes to complete. OnTrackNY is an innovative treatment program for adolescents and young adults who have had unusual thoughts and behaviors or who have started hearing or seeing things that others don’t. OnTrackNY helps people achieve their goals for school, work, and relationships. In many treatment settings you work with just one mental health professional, but with OnTrackNY, you will have the support of an entire team to work with you towards achieving your life goals. The team consists of an outreach and recruitment coordinator who will introduce you to the team and help you decide if the program is a good fit, a primary clinician who will offer you counseling and support and help you learn new skills to cope with what you are experiencing, a psychiatrist who can collaborate with you to make decisions related to medication and help with medical concerns, a peer specialist who shares lived mental health experiences, social tools, and resources to better navigate recovery, a supported education/employment specialist who can help with work or school, and a nurse to support your overall health and wellness. Eligibility Criteria: OnTrackNY services will be available to adolescents and young adults ages 16 and 30 Who have recently begun experiencing symptoms, such as unusual thoughts and behaviors, hearing or seeing things that others don’t, or disorganized thinking, for over a week but less than 2 years. Are willing to work with a diverse team of healthcare professionalsClient First Name Client Last Name Gender 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 Please Specify Date of Birth MM slash DD slash YYYY Client/Contact Phone NumberPhone Number Cell Phone Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Race Ethnicity Non-Hispanic Hispanic African American Caucasian/White Other Primary Language English Spanish Other Reason for Referral Multi Medicaid ID Number Medicare ID Number Referral Source Self CASES Program Outside Agency Referrer Email(Required)
