Bronx Young Adult ACT

Bronx Young Adult ACT is a specialty program that provides comprehensive mental health and case management services to individuals in the community

Please email YACTreferrals@cases.org for more information.

ELIGIBILITY HIGHLIGHTS

Age & Location:

Individuals must be 18 to 28 years old.
Must currently reside in the Bronx.

Clinical History:

Must meet one of the following:

- 2 or more psychiatric hospitalizations
- 1 hospitalization lasting 60+ days
- At least 4 psychiatric emergency room visits in the last 12 months

Mental Health Status:

Must have a primary diagnosis of Serious Mental Illness (SMI), such as:

- Schizophrenia
- Schizoaffective Disorder
- Bipolar Disorder
- Major Depressive Disorder

Program Participation:

Must have difficulty engaging in traditional outpatient mental health services.

Step 1 of 4

25%

Client 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 Number

Medicaid ID(Required)

If you don't have active Medicaid, please enter "n/a"

Previous Medicaid ID

Community Living Situation(Required)

Other:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Current location(Required)

Other:(Required)

Faculty Name(Required)

Current living situation contact(Required)

Facility name (current location)(Required)

Referral Source

Self

Agency

Referring Agency Type(Required)

Is the referring agency a Mental Health provider?(Required)

Yes

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)

Does the client have care coordination?(Required)

Yes

N/A

Care coordination agency name(Required)

Care coordination contact information(Required)

Highest Education Level on Enrollment(Required)

Marital Status(Required)

Race(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

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

Unknown

Type of Program(Required)

Name of Provider(Required)

Provider Phone #(Required)

Provider Email(Required)

Secondary program

Secondary Provider Name

Secondary Provider Phone #

Secondary Provider Email

Has applicant had any psychiatric hospitalizations in the last 5 years?(Required)

Yes

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

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

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

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

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

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)

File

Max. file size: 64 MB.