Who is filling out this form?
* must provide value
Myself
Somebody else
Yes
No
INTRODUCTION SCRIPT - ADMIN ONLY ______ , one of the Administrators with the Center. In order to help you get connected, I'll need to ask you a few questions about yourself. If you're eligible for our services, then I'll tell you a bit more about us and how to get started. Can you please start by telling me your name? Name of staff taking referral:
Amanda Amodio, LCSW Ashley Doukas, PhD Aysha Khan Charlotte Mcdermott, LCSW Cristina Enriquez, LCSW Deborah Marin, MD Elaine (Yi Ling Li), MD Hira Ali, MPH Jessie (Zhixi Liu), LCSW Jonathan DePierro, PhD Kiley Callahan, PhD Laiyu Tsang, MD Lucy Wood, PhD Mallory Stellato, MPH Meana Hong Michelle Roach, BS Paola Suquinagua, MBA Scarlett Ho, PhD Stefanie Perez, LCSW Vansh Sharma, MD Vilma X. Prieto, BA Wuraola Sosina, PhD Other
Date and time of Contact:
Now M-D-Y H:M
Thank you for expressing interest in services provided by the Mount Sinai Center for Stress, Resilience and Personal Growth (CSRPG). CSRPG provides confidential, effective behavioral health services including psychotherapy and/or medication managements to adults (age 18+). Please take a moment to complete this referral form so that we can follow up with you. This form must be completed by the person who is seeking services.
Are you a MSHS faculty or staff member or trainee? * must provide value
Yes, I am a MSHS faculty member, staff member, or trainee.
Yes, I am a dependent, spouse, or partner of an MSHS faculty member, staff member or trainee.
No, I am not a MSHS faculty member, staff member, trainee or a dependent, spouse or partner.
First Name
* must provide value
Last Name
* must provide value
Phone Number
* must provide value
Email Address
* must provide value
How would you like to identify your gender?
Female/woman
Male/man
Non-binary
Transgender female/trans woman
Transgender male/trans man
Prefer not to say
Other
What are your preferred pronouns?
She/Her He/Him They/Them Other (please specify) Prefer not to say
What is your preferred language?
English
Spanish
Spanish
Cantonese
Russian
Italian
Haitian
Other
Other language: * Disclaimer: If we do not have an interpreter or translator for a specific language, we will make every effort to find someone who can assist in that language.
Date of birthPlease provide your date of birth. This helps us verify your identity in order to provide services and also to facilitate referrals if needed. CSRPG does not treat patients younger than 18 years of age.
* must provide value
Today M-D-Y You must be 18 years or older to proceed.
Now M-D-Y H:M
Which of these roles best describes your role at Mount Sinai?
Administrator (e.g., department chair, dean, director) Administrative support (e.g., secretary, program coordinator) Advanced Practice Providers (PA/NP) Behavioral Health (social workers, chaplains, psychologists, child life specialists) Nurses (RN/LPN) Non-Medical Support Staff (e.g., IT, billing, patient transport, security) Pharmacy/radiology/dietitian Physicians (attendings, surgeons) PT/OT Researcher/Education/Training (e.g., research faculty, research assistant, nurse educator) Resident Students (med, PhD) Fellow Medical support staff (e.g., medical assistants, phlebotomist) Not employed by Mount Sinai
What is your primary location of employment or that of your relation?
I am a Dependent Mount Sinai Hospital Mount Sinai Brooklyn Mount Sinai South Nassau Mount Sinai Downtown/Beth Israel Mount Sinai West Mount Sinai Morningside New York Eye and Ear Infirmary of Mount Sinai Mount Sinai Queens Icahn School of Medicine at Mount Sinai Mount Sinai Corporate (42nd Street) Elmhurst Queens Hospital Center (QHC) Not employed by Mount Sinai
What insurance carrier do you have?
* must provide value
UMR Anthem Blue Cross Blue Shield Aetna 1199 Cigna Self-Pay Other
What insurance carrier do you have?
* must provide value
Aetna Cigna Other
Is this a Mount Sinai-administered health plan?
Yes
No
What is your preferred contact method?
* must provide value
What are the best days/time best to reach you?
Do you prefer virtual or in-person?
If planning to refer to CSRPG:
Yes
No
Unsure/need more information
- ADMIN ONLY - In the event that we recommend a different treatment service within Mount Sinai, do you provide us consent to share the information from this interview with another MSHS mental health provider?
If after the evaluation, we recommend a referral for mental health treatment at MSHS, do you give consent for us to share the information you provided with MSHS mental health providers?
Yes, I consent to sharing of screening information with MSHS mental health providers No I do NOT consent to sharing of screening information with MSHS mental health providers
Thank you for taking the time to complete this form. A member of our team will contact you within two weeks.
Referral Information - ADMIN ONLY Can be filled out as soon as the e-mail/initial call is received and/or prior to calling the patient.
If an incident referral, what triggered this?
If other, please describe:
Have you attended any groups/workshops/huddles/educational talks/tabling events presented by CSRPG?
Yes
No
How did the patient come us?
"Method"
Telephone
E-mail
In person
App contact
eConsult
Incident referral
Provider-initiated referral
Referral form
If other, please describe:
How did you hear about us?
"Source"
Accolade/Sinai benefits
Colleague/supervisor
E-mail blast
Family member/friend
Flyer/magnet
Internet search
MyChart
Orientation
OWBR/Wellness champions
PAS (Access Center)
Provider (e.g., PCP)
UMR Care Coordination
Workshop/huddle/Tabling
Other
Provider-initiated referral follow-up:
Cardiac Monitoring Program
Diabetes Care Program
EAP
EHS
Epic eConsult
MSHS Psychiatry
Primary/specialty care
PWC
Referral Access Program (RAP)
(If unknown, ask): Are you calling to set up a mental health appointment?
Treatment
Workshops
Request for unit support
Asking for friend/family/colleague
Other
If other, please describe:
If scheduling a virtual appointment with us: Where will you be physically located when you are completing the virtual visit?
Brief Summary
Safety resources provided
Reason for emergency referral:
Is the caller eligible for CSRPG services?
Yes
No
Don't know/need consultation
Which CSRPG arm is this caller eligible for?
Internal: MSHS employee or dependent, 18+, with Sinai insurance.
External: Non-employee/dependent, 18+, with non-Sinai insurance.
Ineligible: Under 18 and/or lacks participating insurance.
Eligible, but not clinically appropriate.
Please explain the reason for ineligibility in more detail:
Age (automatically calculated from DOB)
View equation You must be 18+ to continue.
Stop now
Continue
Today M-D-Y
Amanda Amodio, LCSW Ashley Doukas, PhD Charlotte Mcdermott, LCSW Cristina Enriquez, LCSW Deborah Marin, MD Elaine (Yi Ling Li), MD Jessie (Zhixi Liu), LCSW Jonathan DePierro, PhD Kiley Callahan, PhD Laiyu Tsang, MD Lucy Wood, PhD Scarlett Ho, PhD Stefanie Perez, LCSW Vansh Sharma, MD Wuraola Sosina, PhD Other
If other, please describe:
If not referred to CSRPG for an evaluation, please select the reason why
If other, please describe:
WRAPPING UP/INSTRUCTIONS FOR DE______ with ______ . After we hang up this call, I will e-mail you a link to a registration form that must be completed as soon as possible. Please have your photo ID and insurance card ready when completing the form, as you will be asked to upload a JPEG or PDF of them and will not be able to go back once you start it. The registration form takes about 5-10 minutes to complete. Please note that failure to complete the registration prior to your visit may result in the cancellation of your visit.
Please click here upon completion: Now M-D-Y H:M
Duration of call [in minutes]:
View equation