Mobile Crisis Referral

Mobile Crisis Referral

To make a referral please complete the form below. Referral subjects will be contacted by a crisis worker the next business day. If this is an emergency or the referral subject is in immediate danger please call 911. To speak to a certified peer specialist 24/7 please call 800-440-8074.
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Best time to contact:
Email Address (for mobile crisis contact purposes only)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the individual an Essex County resident?

YesNoUnknown
Date of Birth

MonthDayYear
Gender*
Veteran Status
Insurance Provider
Insurance ID Number (CIN # if available)
Emergency contact for the individual
Relationship
Phone Number

Area CodePhone Number
Name of person making referral (Required. If self-referral, enter Self.)*
Referring Agency/Organization/School*
Phone Number*

Area CodePhone Number
Email*
Your relationship to the individual
Your last contact with the individual was:

In personOver the phoneElectronic (email, text, social media)Third party
What crisis is the individual currently experiencing? Check all that apply:

Mental Health CrisisSuicidal ThoughtsHistory of Suicide Attempt(s)Experienced a Loss to SuicideMedical CrisisHousing CrisisHealth InsuranceMedication IssueEntitlement ProgramsAlcohol/Substance Use DisorderDomestic ViolenceLegal IssuesRecent Mental Health HospitalizationRecently Missed AppointmentsOther/Psychosocial, Describe Below
Please describe the nature of the crisis and the items checked above:*
Symptoms the consumer is currently experiencing*
Medical Conditions
If known
Medications
If known
Suicide Risk Assessment*
Alcohol/Substance Use and Treatment History
If known
Safety Assessment*
history of violence, weapons in home, dangerous dogs, known drug location, etc.
Additional comments:
Does the individual agree to MHA Mobile Crisis Services?

YesNoNot sure/May agree at a later time
Upload Signed Release of Information (if available)

Cancelof
Should be Empty: