Bronx YA ACT Referral Form Step 1 of 4 25% Bronx Young Adult ACT is a specialty program that provides comprehensive mental health and case management services to individuals in the community who are: 18 to 28 years oldCurrently reside in the Bronx Have a primary diagnosis of Serious Mental Illness (e.g. Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder) Have 2 or more psychiatric hospitalizations or 1 hospitalization 60+ days or at least 4 psychiatric emergency room visits in the last 12 months Have struggles with attending traditional outpatient mental health services Please email YACTreferrals@cases.org for more informationClient First Name(Required) Client Last Name(Required) Birth Date(Required) MM slash DD slash YYYY Gender(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 Please Specify Social Security NumberMedicaid ID(Required)If you don't have active Medicaid, please enter "n/a"Previous Medicaid ID Community Living Situation(Required)Please SelectPrivate residenceHomeless (Shelter)Homeless (Street)Supported/Supportive HousingResidential treatment facilityUnknownOtherOther:(Required) Address(Required) 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 Current location(Required)Please SelectAcute care hospitalState psychiatric centerForensic state psychiatric centerJailPrisonCommunityOutside of NYCMissingUnknownOtherOther:(Required) Faculty Name(Required) Current living situation contact(Required) Facility name (current location)(Required) Referral Source Self Agency Referring Agency Type(Required)Choose AgencyACT/FACT/SPACTAcute Inpatient Unit/HospitalAOTCare Management AgencyCity HallCPEP/Psychiatric ERCRTCriminal Justice Involved (probation, parole, Legal Aid, courts, diversion programs)DANYDHSHEATHousing ProviderHRAIMTJail/CHS/RikersMCOMobile Crisis Team (MCT)MOCJOMH Forensic ICM TeamOutpatient Mental Health Provider/Private PractitionerPrison (Federal)Prison (State, CNYPC)Residential Treatment Facilities (RTF)State PCSubstance Use Treatment ProviderSupervision Release ProgramOtherIs the referring agency a Mental Health provider?(Required) Yes No Referring Agency(Required) Referring Worker First Name(Required) Referring Worker Last Name(Required) Referring Worker Phone #(Required) Referring Worker Email(Required) Address(Required) Managed Care Organization (MCO)Please SelectAetna Health IncAffinity Health Plan IncAmerigroupAmida Care IncCapital District Physicians Health Plan IncCatholic Health First PHSPEmblem HealthEmpire HealthChoice HMO IncExcellus Health Plan IncFidelisHealth Insurance Plan of Greater New YorkHealth Net of New York IncHealthFirst Health Plan IncHealthFirst PHSP IncHealthNow New York IncHealthPlus, LLCHudson Health Plan IncIndependent Health Association IncMVP Health Plan IncMetroPlus Health Plan IncMetroPlus Health Plan, Inc Special Needs PlanMetroplus Partnership CareNeighborhood Health Providers IncNew York State Catholic Health Plan IncNew York-Presbyterian Community Health Plan IncOHP PHSP IncOxford Health Plans IncUnited HealthCareVisiting Nurses Services (VNS) Choice SelectWellcare of New YorkYourCare Health Plan IncUnenrolledUnknownOtherDoes the client have care coordination?(Required) Yes No N/A Care coordination agency name(Required) Care coordination contact information(Required) Highest Education Level on Enrollment(Required)Please SelectNo formal education or kindergarten onlyGrammar school (Grades 1 to 5)Junior high school (Grades 6 to 8)Some high school (Grades 9 to 11)GED or TASCHigh School DiplomaBusiness, vocational, or technical trainingSome college but no degreeAssociate's degreeBachelor's degreeGraduate degreeUnknownOtherMarital Status(Required)Please SelectSingle, never marriedCurrently marriedCohabitating with significant other/domestic partnerWidowedSeparatedPending divorceDivorcedUnknownOtherRace(Required) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White (includes Middle Eastern and North African) Declines to answer Unknown (no information available) Other Other(Required) Ethnicity(Required) Hispanic or Latino/Latina Non-Hispanic or Non-Latino/Latina Declines to answer Unknown (no information available) Primary Language(Required) English Spanish Bengali Hindi Urdu Other Other(Required) AOT Status(Required) Application in progress Application submitted Active investigation Didn't meet criteria Current order Order expired Voluntary Pending/Adjourned Unknown If client has a current AOT order, please email order to YACTreferrals@cases.org Known past history of AOT(Required) Yes No Unknown Criminal Justice Involvement(Required) No past history of criminal justice involvement Currently monitored by Supervised Release Program Currently probation Currently on parole Current detention - jail Current detention - prison Currently involved in a Diversion Program Pending matter in Criminal Court Pending matter in Family Court Past adult criminal conviction(s) Criminal Justice Involvement within past 12 months Past juvenile delinquent finding(s) Past probation Past parole Past county jail Criminal Justice Involvement more than 12 months Current Order of Protection Unknown Other Other(Required) NYSID # (if known) Current employment status(Required) Paid competitive full-time (35+ hrs/week) Paid competitive part-time Temporary, seasonal, or per diem Internship or volunteer Transitional employment None Unknown Other Other(Required) Current Income Sources(Required) Earned income (i.e. employment income) Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) VA Benefits Private disability insurance Workers Compensation Temporary Assistance for Needy Families (TANF) Child support Alimony and other spousal support Trust Unknown None of the above Other Other(Required) DSM 5 Diagnosis(Required) Physical Health Diagnosis(Required) Asthma COPD (Chronic Obstructive Pulmonary Disease) Metabolic Syndrome Coronary heart disease Diabetes High cholesterol High blood pressure Obesity Liver Disease/Cirrhosis None of the above Unknown Other Other(Required) Applicant adherence to medication regimen(Required) Takes medication as prescribed Takes medication as prescribed most of the time Sometimes takes medication as prescribed Rarely takes medications as prescribed Never takes medications as prescribed Refuses medication Medication not prescribed Unknown Other Other(Required) Is client currently connected to treatment (i.e. going to mental health clinic, seeing a psychiatrist, has a clinic assigned, etc.)?(Required) Yes No Unknown Type of Program(Required)Please SelectACTClinic TreatmentComprehensive PROS with ClinicComprehensive PROS w/o ClinicDay TreatmentHarm Reduction ServicesIntensive Psychiatric Rehab (IPRT)Medication Assisted TreatmentOutpatient Substance Use ServicesPrivate PractitionerOtherName of Provider(Required) Provider Phone #(Required) Provider Email(Required) Secondary programPlease SelectACTClinic TreatmentComprehensive PROS with ClinicComprehensive PROS w/o ClinicDay TreatmentHarm Reduction ServicesIntensive Psychiatric Rehab (IPRT)Medication Assisted TreatmentOutpatient Substance Use ServicesPrivate PractitionerOtherSecondary Provider Name Secondary Provider Phone # Secondary Provider Email Has applicant had any psychiatric hospitalizations in the last 5 years?(Required) Yes No How many psychiatric hospitalizations(Required) Please indicate dates and facilities of each psychiatric hospitalization(Required)Has applicant had any ER visits for psychiatric conditions in the last 5 years?(Required) Yes No How many ER visits for psychiatric conditions(Required) Please indicate dates and facilities of each ER visits for psychiatric conditions(Required)Has applicant had any mobile crisis visits in the last 5 years?(Required) Yes No How many mobile crisis visits(Required) Please indicate dates of each mobile crisis visit(Required)Has applicant attended any mental health programs (i.e. mental health clinics, ACT, Care Coordination, PROS, OPD, etc.) in the last 5 years?(Required) Yes No How many mental health programs attended(Required) Please provide dates and providers of each mental health program attended(Required)Has applicant attended any substance use programs (i.e. substance use treatment program and/or day treatment) in the last 5 years?(Required) Yes No How many substance use programs attended(Required) Please provide dates and providers of each substance use program attended(Required)Please identify which risk behaviors the applicant has engaged in: None Unknown Expressed suicide threat Attempted suicide Physically harmed self Taken property w/o permission Damaged or destroyed property Experiencing homelessness Created a public disturbance Verbally assaulted another person Threatened assault or physical violence Been suspected of sexual abuse of a child/adult Physically abused and/or assaulted a child/adult Engaged in arson Was a victim of physical or sexual abuse Wanders or runs away Transient/moves frequently High recidivism of incarceration No engagement after multiple referrals Attempted or committed homicide Other Other(Required) Please explain any of the above selected:(Required)Reported Substance Use(Required) Yes No Drug of choice(Required) Alcohol Amphetamines type stimulants Cannabis Cocaine/Crack Hallucinogens Inhalants Medications Methamphetamine Opioids Synthetic Drugs None Unknown Other Other(Required) Supporting documentation for this referral. Please upload documentation for this referral (Consent and Release Forms, Psychosocial Evaluation, Psychiatric Evaluations, AOT order if applicable)FileMax. file size: 64 MB.
