Welcome to the Mount Sinai Health System Ambulatory Behavioral Health Referral Form. Please read the following information carefully. The Mount Sinai Health System offers a range of outpatient behavioral health (BH) services both via telehealth and in person at the following Mount Sinai locations in Manhattan: Upper East Side, Upper West Side, and Lower East Side. Referrals received through this form are routed to one of our locations based on a variety of criteria. Telehealth services: To be eligible, patients must be located in New York at the time of the virtual visit. From time to time, or based on clinical or regulatory needs, providers may require in-person attendance. For referrals made on behalf of a patient or family member, please ensure the person is aware of the reason for referral to behavioral health services, that a referral has been made on their behalf, and the reason for the referral. Patients should expect a call from the outpatient BH program and understand that the BH program may leave a voicemail message. Please allow 2 business days for referral review and response.
Today's Date:
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Today M-D-Y
How did you hear about our services:
First Name
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Last Name
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Date of Birth
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Today M-D-Y
View equation Who is making the referral (select option that best describes your relationship to the patient):
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Acute Care Service (inpatient, inpatient CL) CPEP or Psychiatric ED (CPEP, PsychED, CL) Detoxification/Rehab Service (inpatient) Mobile Crisis Team (MCT) MSHS BH Ambulatory Care Program (Psychiatric and Addictions) Non-BH MSHS Ambulatory Care Program Mount Sinai Social worker referring through the MSHP Referral Access Program (RAP) GUIDE CMS geriatric medicine program Community provider (non MSHS employee or provider) Patient or family member/advocate of a patient seeking outpatient behavioral health services
Mobile Crisis Team Name
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Bellevue Hospital MCT (NYC H+H) Beth Israel Medical Center MCT (Mount Sinai) Bronxcare MCT Brookdale Hospital MCT Columbia Presbyterian Hospital MCT Elmhurst Hospital MCT (NYC H+H) Harlem Hospital MCT (NYC H+H) Jacobi Hospital MCT (NYC H+H) Jamaica Hospital MCT Kings County Hospital MCT (NYC H+H) Lincoln Hospital MCT (NYC H+H) Morningside Mobile Crisis Team (Mount Sinai) Mobile Crisis Team) NY Presbyterian/ Weil Cornell Medical College MCT Queens Hospital MCT (NYC H+H) Richmond University Medical Center MCT (RUMC) VNS Health Mobile Crisis Team: Bronx (Adult) VNS Health Mobile Crisis Team: Brooklyn (Adult) VNS Health Mobile Crisis Team: Queens (Adult) Woodhull Hospital MCT (NYC H+H) Children's Mobile Crisis Team: Bronx Children's Mobile Crisis Team: Brooklyn Children's Mobile Crisis Team: Manhattan Children's Mobile Crisis Team: Queens Children's Mobile Crisis Team: Staten Island Co-response Unit- NYC DOHMH
Please Note: If you are an MSHS primary care provider (except MSDMG), please leverage the MSHP Referral Access Program to make this referral. A social worker aligned with your practice can help place this referral and coordinate with your patient for follow through. Refer through your practice-embedded social worker or via the Epic Order to MSHP Care Management.
Are you a provider from the Bellevue CPEP?
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Yes No
Are you a provider at a Mount Sinai Facility?
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Yes No
Which Mount Sinai campus are you making the referral from?
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Mount Sinai Behavioral Health Center Mount Sinai Hospital Mount Sinai Morningside Mount Sinai West
Have you already scheduled an appointment for this patient?
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Yes
No
Date of Scheduled Appointment
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Which hospital/ health system are you referring from?
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BronxCare Health System Brookdale University Hospital and Medical Center Flushing Hospital Gouverneur Hospital Gracie Square Hospital Jamaica Hospital Lennox Hill Hospital Maimonides Medical Center Montefiore Medical Center NYC Health + Hospitals/ Bellevue Hospital Center NYC Health + Hospitals/ Elmhurst Hospital Center NYC Health + Hospitals/ Harlem Hospital Center NYC Health + Hospitals/ Jacobi Medical Center NYC Health + Hospitals/ Kings County Hospital Center NYC Health + Hospitals/ Lincoln Medical and Mental Health Center NYC Health + Hospitals/ Metropolitan Hospital Center NYC Health + Hospitals/ North Central Bronx Hospital NYC Health + Hospitals/ Queens Hospital Center NYC Health + Hospitals/ South Brooklyn Health/Ruth Bader Ginsburg Hospital NYC Health + Hospitals/ Woodhull Medical and Mental Health Center New York Presbyterian- Brooklyn Methodist Hospital New York Presbyterian- Columbia University Irving Medical Center New York Presbyterian- Lower Manhattan Hospital New York Presbyterian- Queens New York Presbyterian- Weil Cornell Medical Center NYU Langone Medical Center Richmond University Medical Center Staten Island University Hospital St. Barnabas Hospital The New York Foundling Hospital Zucker Hillside Hospital
Program/ Practice Name:
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Primary Provider Name/ Referring Provider Name:
Referring Provider Email
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Referring Provider Phone Number:
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Referral Source Email
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Referral Source Phone
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Preferred Method of Contact
Are you referring to our Intensive Outpatient or Partial Hospital Programs?
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Yes No
If yes, please indicate which one
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Intensive Outpatient Program (IOP) Partial Hospital Program (PHP)
PHP is a six-week program with required attendance five days a week. Please ensure that the patient understands and is comfortable with this level of engagement.
IOP is a six-week program with required attendance five days a week. Please ensure that the patient understands and is comfortable with this level of engagement.
Are you referring to our On Track program?
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Yes No
The MSH OnTrackNY program is a New York State Coordinated Specialty Care (CSC) program grounded in research and designed for teens and young adults ages 15.5-30 who have experienced a first episode of psychosis. The MSH OnTrackNY treatment team supports participants make meaning of their experiences and pursue their goals related to school, work, and relationships. Our mission is to provide premier, evidence-based and recovery-oriented services including psychiatric treatment, individual and group psychotherapy, employment and educational support, and family education and support, for participants and their families. The program offers care from the CSC team for up to two years, based on participants' needs and preferences. The team consists of a Team Leader, a psychiatrist, Primary Clinicians, a Supported Education and Employment Specialist, and a Peer Specialist.
Onset of psychotic symptoms
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Less than 2 years 2 years Greater than 2 years
Presenting concerns warranting referral include
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Is this referral for someone experiencing distress due to their role as a caregiver to a Mount Sinai patient who is living with:https://redcap.link/caregiversupportprogram
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Yes
No
Are you seeking treatment for alcohol or substance use?
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Yes No
What substance are you struggling with?
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What type of alcohol or substance use treatment are you looking for?
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Is the patient pregnant?
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Yes No
What type of mental health treatment are you looking for:
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Please explain the reason for referral in a few sentences. The more detail you provide, the easier it is to expedite this referral.If you are seeking to a connect with a specific provider, please indicate their name here; please note that we cannot guarantee that this request will be accommodated.
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PRIMARY Insurance coverage:Please confirm with patient that insurance information is correct to avoid delays in verification and appointment scheduling. Please send copy of patient's insurance card, if available.
If the patient's insurance is not on this list, it is likely that we do not participate with that insurance Managed Medicare Plans , please select "Managed Medicare (Medicare Advantage);" for example, for a patient with Aetna Medicare Advantage, select "Managed Medicare (Medicare Advantage)" and then write in "Aetna" under Medicare Advantage Plan name Managed Medicaid plans , please select from the options provided; please do not select "Medicaid (fee-for-service/ "straight" Medicaid)" for Managed Medicaid plans. Please do not select insurances noted as "(Commercial)" for Medicaid or Medicare enrolled patients Emblem Health -- MSHS does not accept the NYCEPPO plan Anthem/Empire BC/BS -- MSHS does not accept Individual Marketplace (Gatekeeper) and Medicare Advantage plans * must provide value
Aetna Commercial AmidaCare Plan Bright Health NY - Medicare Cigna Behavioral Health (Commercial) Emblem Health Anthem/Empire BC/BS (Commercial) Anthem/Empire BC/BS (Healthplus) Fidelis Care Plan Healthfirst Health Plan Local 1199 Managed Medicare (Medicare Advantage) Medicare Part B - Outpatient Services Medicaid (fee-for-service/ "straight" Medicaid) MetroPlus Health Plan Out of Network/Self Pay UMR Top Tier - MSH Employee Wellcare Health Plan 32BJ SIEU
Medicare Advantage Plan
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PRIMARY Insurance ID#
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SECONDARY Insurance coverage:
Aetna AmidaCare Plan Bright Health NY - Medicare Cigna Behavioral Health Emblem Health Anthem/Empire BC/BS (Commercial) Anthem/Empire BC/BS (Healthplus) Fidelis Care Plan Healthfirst Health Plan Local 1199 Managed Medicare (Medicare Advantage) Medicare Part B - Outpatient Services Medicaid (fee-for-service) MetroPlus Health Plan UMR Top Tier - MSH Employee Wellcare Health Plan 32BJ SIEU
Patient's Contact Number:
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Patient's Email Address:
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Address (Street, Apt, Zip Code):
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Patient can receive mail at this address
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Yes No I'm Not Sure
Is patient the primary insured?
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Yes No I'm Not Sure
Is patient home address the same as the address on their insurance?
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Yes No I'm not sure
Please provide Address (Street, Apt, Zip Code) on insurance card:
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Please provide Name, Date of Birth, and Address (if different from patient) of primary insured
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Female
Male
Female
Male
Transgender
Non-binary/Non-conforming
Other
Prefer Not To Say
He/Him
She/Her
They/Them
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Prefer Not To Say
Unknown
Spanish/Hispanic/Latino
Not Spanish/Hispanic/Latino
Prefer Not To Say
Does the patient require mental health services in a language other than English:
Yes No I'm Not Sure
Which language does the patient need mental health services in:
Is Patient a Mount Sinai Employee?
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Yes
No
Additional Information for Child Patients
Daycare Preschool or Pre-k (3-k or 4-k) Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th None - graduated None - other College
Primary Caregiver:
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Biological Parent(s) Legal Guardian Foster Parent Kinship Foster Parent
Parent/Caregiver 1 Name
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Parent/Caregiver 1 Date of Birth:
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Today M-D-Y
Parent/Caregiver 1 phone
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Parent/Caregiver 1 E-mail
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Does the patient have another caregiver?
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Yes No I'm not sure
Secondary Caregiver:
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Biological Parent(s) Legal Guardian Foster Parent Kinship Foster Parent
Parent/Caregiver 2 Name
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Parent/Caregiver 2 Date of Birth:
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Today M-D-Y
Parent/Caregiver 2 Phone
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Parent/Caregiver 2 E-mail
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Primary language spoken by parents
English Spanish Other
Do(es) the patient's parent/caregiver require language interpretation services.
Yes No I'm Not Sure
List language(s) that parent/caregiver needs intepretation services in.
Does the patient have an Individualized Education Plan (IEP)?
Please provide more details on the patient's IEP, including eligibility, if known.
Does the patient have any known history of psychological testing (ex. school testing, early intervention evaluation, CSE evaluation, neuropsychological testing, intelligence or psychoeducational testing)?
Yes No I'm Not Sure
Please provide details on history of psychological testing, if known.
Is the patient currently in foster care, or care outside of the custodial parent
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Yes No I'm Not Sure
Inpatient Discharge Planning Please note: We aim to arrange an outpatient appointment within a 5 day window from the date of discharge.
Anticipated Discharge Date
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Today M-D-Y
Inpatient social worker coordinating discharge planning
Inpatient attending name
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Is patient being discharged to their home address?
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Yes No
Please provide Address (Street, Apt, Zip Code) patient is being discharged to:
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Patient's Level of Risk
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High Moderate Low I'm Not Sure
MSHS Suicide Risk Assessment/Violence Risk Assessment (SRA/VRA) Available:
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Yes No I'm Not Sure
Columbia Suicide Severity Rating Scale (C-SSRS) Available:
Yes No I'm Not Sure
SRA/VRA or C-SSRS (If Available)
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Date of Last SRA/VRA or C-SSRS (If Available)
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Emergency Contact Name
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Emergency Contact phone
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Emergency Contact Email
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Emergency Contact Relationship to Patient
Please note: MSHS Psychiatric outpatient services are not equipped to manage medical emergencies. Please review and confirm the following carefully with the patient:
Has the patient had a recent (~3-6 months) psychiatric inpatient stay or CPEP/Psychiatric Emergency Department visit:
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Yes No I'm Not Sure
Please provide details of most recent inpatient stay or CPEP/ Psychiatric Emergency Department visit, if available.
Does the Patient Currently Have an AOT Order:
Yes No I'm Not Sure
Case Manager Phone Number
Does the patient currently have any open legal cases or pending action:
Yes No I'm Not Sure
If yes, provide a brief summary
Has the patient ever been diagnosed with any of the following psychiatric conditions (please check all that apply)
Is the patient on a long acting injectable (LAI):
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Yes No I'm not sure
Please select the patient's current injectable medication:
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Aristada Invega Sustenna Invega Hafyera Invega Trinza Vivitrol Haldol Prolixin Risperdal Consta Abilify Maintena Sublocade/Brixadi
Please provide F-Code (this is required to receive prior authorization for the LAI)
Date/Dose of last LAI received
Approximate date when next LAI dose is needed:
Today M-D-Y
Does the patient have Autism Spectrum Disorder (including high levels of functioning), Intellectual Disability, or Pervasive Developmental concerns?
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Yes No I'm Not Sure
If Yes, Please elaborate:
Patient may benefit from services through the New York State Office for People with Developmental Disabilities. Please visit their website (https://opwdd.ny.gov/) or call their offices (866-946-9733) for additional information.
Does the patient have a history of aggression, violence, or significant interpersonal issues in group settings?
Yes No I'm Not Sure
Please list any other preferences (such as wheelchair accessibility, hours of operation, provider characteristics) that would make it easier for the patient to maintain services.
This referral appears to be eligible for review by the Psychiatry Faculty Practice Association (FPA) team. If you are seeking services specifically through one of the MSHS Psychiatric clinics, please indicate your location preference, and we will route your referral accordingly. If you select 'No location preference,' the referral will be routed to the FPA.
***Inpatient and Emergency Department Referrals must select one of the clinics for Location Preference***
Preferred Location
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Lower East Side/ Behavioral Health Center (45 Rivington Street) Upper East Side/ Mount Sinai Hospital (Adult: 1160 5th Avenue / Child: 1240 Park Avenue) Upper West Side/ Harlem Health Center (158 W 124th St) No Location Preference
Location Preference:This referral appears to be eligible for review by the Psychiatry Faculty Practice Association (FPA) team. If you are seeking services specifically through one of the MSHS Psychiatric clinics, please indicate your location preference, and we will route your referral accordingly. If you select 'No location preference,' the referral will be routed to the FPA.
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Lower East Side/ Behavioral Health Center (45 Rivington Street) Upper East Side/ Mount Sinai Hospital (Adult: 1160 5th Avenue / Child: 1240 Park Avenue) Upper West Side/ Harlem Health Center (158 W 124th St) No location preference
Please note: The Harlem Health IOP is temporarily not accepting new referrals. All IOP referrals are presently being routed to the IOP at Mount Sinai Behavioral Health Center (45 Rivington Street) regardless of the preferred location selected.
Preferred Location
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Lower East Side/ Behavioral Health Center (45 Rivington Street) Upper West Side/ Mount Sinai Harlem Health Center (158 W 124th St)
Preferred Location
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Upper East Side/ Mount Sinai Hospital (1160 5th Avenue)
Preferred Location
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Lower East Side/ Behavioral Health Center (45 Rivington Street)
Review and response to this referral may take up to 2 business days. This referral is not appropriate for a patient in need for emergency psychiatric services. In case of a medical emergency that needs immediate attention, call 911 or go to the nearest emergency room. In the event of a psychiatric emergency, danger to self or others, or need immediate support, call or text 988, chat with 988 at https://988lifeline.org/chat/, or go to the nearest emergency room.
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Yes
Non-MSHS referring providers --please upload most recent Intake Assessment
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Non-MSHS Referring Providers -- please upload most recent Progress Notes
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Non-MSHS Referring Providers --please upload Group Therapy Notes
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Please note: Referrals that have been successfully submitted and received will see a "Thank you for your referral" confirmation message on the screen. If you receive a pop-up indicating missing required fields, please complete all required fields and "Submit."
FPA Eligible_For Internal Processing
View equation FPA Eligible
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Yes No
READ ONLY. FOR OFFICE USE.