Adult Health Home Referral Form
Full Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone #2
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Language
Please Select
Arabic
Bengali
English
French
Haitian Creole
Hindi
Persian
Russian
Spanish
Urdu
Yiddish
Other
Medicaid ID / CIN
*
Gender
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Worker's Name
*
Referring Location/Source [REPLACED W DROPDOWN]
*
Referral Location/Source
*
Please Select
785 Atlantic Avenue, Brooklyn
90 Sands Street, Brooklyn
201 Bay Street, Staten Island
447 Fulton Street, Brooklyn
2-19 Beach 59th Street, Rockaway
155-15 Jamaica Avenue, Jamaica
165-08 88th Avenue, Jamaica
West 125th & Lenox Avenue, Harlem
Lincoln Hospital, Bronx
3rd Avenue & East 149th Street, Bronx
5th Avenue & 53rd Street, Sunset
1912 Mermaid Avenue, Coney Island
Nostrand Junction, Brooklyn
Barlcays Center, Brookyln
StillwellTrain Station, Coney Island
Flatbush Avenue & Church Avenue
Woodhull Hospital, Brooklyn
1642 Coney Island Avenue Office
1061 Flatbush Avenue Office
1791 Lexington Avenue Office
Other
Other location
*
Referring Worker's Email
example@example.com
One Chronic Condition
HIV / AIDS
Sickle Cell
Serious Mental Illness
Please Specify Serious Mental Illnesses
ADD / ADHD
Anxiety Disorder
Bipolar
Borderline Personality Disorder
Cyclothymic Disorder
Depression
Dissociative Disorder
Feeding & Eating Disorders
Gender Dysphoria
OCD
PTSD
Schizophrenia
Somatic Symptom & Related Disorders
Substance Related & Addictive Disorders
Trauma & Stressor Related Disorders
Other
Two or more Chronic Conditions
Arthritis
Asthma
BMI > 25 (Obesity)
Cancer
Diabetes
Heart Disease
Hypertension (High Blood Pressure)
Liver Disease
Migraines
Skin Condition (e.g. Psoriasis)
Thyroid Disorder
Other
Primary Support Need (At least one of the following must be selected)
*
Requires assistance connecting or re-engaging with medical or behavioral health providers (i.e., PCP, mental health provider, HIV specialist, sickle cell specialist, neurologist).
Currently managing a medical or mental health condition requiring provider support or care coordination.
History of frequent hospitalizations or recent hospitalization, surgery, or discharge within the past 3 months.
Difficulty adhering to prescribed medications due to cognitive, emotional, or physical challenges.
At risk of self-harm or suicidal ideation, or recently discharged from a mental health or detox facility.
Need help losing weight (Nutritionist, Diet meal plans)
Currently experiencing homelessness or at imminent risk of eviction.
Residing in unsafe, overcrowded, or otherwise unstable housing conditions (e.g., abuse, shelter, temporary arrangements).
Seeking support with NEW housing applications for 3 housing programs (Section 8, ESSHI, NYHER) where enrollment periods are currently open.
Youth (ages 15–26) transitioning out of foster care or fleeing violence without a stable living arrangement.
Requires assistance for NEW application nutrition programs such as SNAP (Food Stamps), Meals on Wheels (Disabled or 60+ age), or WIC (Vouchers for Mothers with Children 4 years and under and Pregnant women).
Needs support with financial assistance programs (e.g., Cash Assistance, One Shot Deal).
Requires help applying for SSI, SSDI, Medicare, or HEAP (Home Energy Assistance Program).
Needs assistance with non-emergency transportation applications (e.g., MAS, Access-A-Ride).
Recent loss or change in primary caregiver due to death, incarceration, separation, or institutionalization.
Household impacted by domestic violence or recent changes in guardianship leading to instability.
Recently released from incarceration (jail, prison, or juvenile facility) within the last 3 month
Currently involved with mandated services such as Adult Protective Services (APS).
Medicaid coverage includes special program codes (i.e., H1/H9 for HARP)) indicating need for intensive support services.
Secondary Support Needs (Optional – check all that apply)
Needs assistance connecting with additional providers such as a dentist, physical therapist, or vision specialist, cardiology, dermatology)
Requires support coordinating care with a pharmacy for ongoing medications or prescriptions.
Needs help scheduling or following up on specialty DR. appointments
Needs help recertifying Medicaid programs such as Medicaid, SNAP, and SSI.
Apply for Over-the-Counter (OTC) benefits for members enrolled in Medicare Advantage (Part C)
Needs support accessing Durable Medical Equipment (DME) or other med supplies.
Has a housing voucher (e.g., Section 8, CityFHEPS) and needs help locating eligible housing units.
Requires assistance following up on pending housing applications or communicating with housing agencies.
Needs support completing housing-related paperwork or attending housing appointments.
Interested in applying for jobs and requires assistance with job readiness (e.g., résumé building, interview preparation).
Needs help enrolling in employment training programs like OSHA, HHA or workforce development.
Requires assistance applying for a Reduced-Fare MetroCard due to age, disability, or income eligibility.
Requires help applying for utility assistance programs or preventing service shut-offs.
Needs support accessing local food pantries or clothing assistance programs.
Needs help applying for free phone programs through Medicaid.
Member is living with an elderly or disabled caregiver who needs additional support.
Needs help coordinating services between multiple caregivers or household members.
Member or caregiver needs parenting support, classes, or respite care.
History of multiple system involvement without coordinated support, resulting in unstable care.
Needs assistance complying with legal requirements such as probation, parole, or court mandates.
Appropriateness
*
Difficulty navigating system due to member’s (or guardian) physical or behavioral health condition such as transportation, hygiene, managing finances or scheduling medical appointment
Does not have specialist to treat physical or behavioral condition or has not seen a provider (e.g., PCP, BH, etc.) in the last year
Deficits related to lifestyle, illness, or treatment (such as medication side effects,home environment, isolation, cognitive or mental decline like dementia, aging,hospitalization, etc.)
Not adherent to or having difficulty managing treatment or certain medications.
Release from medical, psychiatric, crisis stabilization, residential treatment settings or detox admission, or incarceration in the last 6 months
Currently impacted by violence at home or by intimate partner
Needs assistance applying for/accessing benefits such as SNAP, SSI, Housing Support, HEAP, Cash Assistance, medical entitlements etc
Unable to access food due to financial limitations, inability to shop, dietary restrictions, etc.
Currently homeless or has no stable living arrangement
Recent change in guardianship/caregiver’s or guardian being institutionalized themselves
Other
Goals
*
Needs to connect and re-establish contact with their PCP, mental health provider, HIV specialist, sickle cell anemia specialist, and neurologist
Need help applying for Meals on Wheels
Need help applying for reduced-fare Metro Card
Need help applying for Access-a-Ride
Need help finding doctors/specialists ____________________________________.
Need help scheduling/reminders for appointments
Assistance with medication adherence
Assistance applying for housing programs
Need help getting employment
Need help with pharmacy that delivers medication
Need help with Social Security
Need help with Medicaid recertification
Need help with online mental health provider
Other
Please Specify Doctors/Specialists
Additional Info / Risk Factory / History
Submission Date
*
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Month
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Day
Year
Date
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