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Referral Form for the Partial Hospitalization Program (PHP) at the Mount Sinai-Harlem Health Center

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Thank you for your interest in our program! Please read the following information carefully. We provide an intensive level of highly structured psychiatric care for patients 18+ with acute symptoms but who do not need inpatient care. It is a voluntary short-term program. All PHP referrals must be submitted for review by the patient's referring provider using this form. Review and response to this referral form may take 2-3 business days.

We encourage you to review our PHP program brochure (below) which includes all of our most up-to-date information about program guidelines, admission criteria, insurance eligibility, and more. Patients who understand the PHP treatment model, program expectations, and have ruled out other treatment options before placement tend to benefit most from the program.

Mount Sinai PHP_HHC_Program Brochure.pdf

For questions on submitting new referrals, please reach out to: 212-241-3170 or PHPreferrals@mountsinai.org

Note: This referral form is not appropriate for a patient in need of emergency psychiatric services. In the 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 for immediate support, call or text 988, chat with 988 at https://988lifeline.org/chat/, or go to the nearest emergency room.

Please see below an overview of our PHP program.

Schedule: In-person Monday through Friday 9:30am to 3:00pm
Format: Patients attend 5 groups per day plus two additional individual sessions per week (individual therapy and medication management)
Length of program: We ask for a minimum 2-week commitment; the longest we are licensed to keep patients enrolled is 6 weeks
Intake: Admission is based on clinical review and availability
Insurance coverage: We are in-network with a variety of insurance companies; we can review your patient's policy and confirm coverage and/or OOP fees
Location: Mount Sinai-Harlem Health Center: 158 West 124th Street (5th Floor), New York, NY 10027

Please confirm that the patient has verbalized understanding of the PHP program requirements and has consented to this referral.

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Yes

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Are you making an internal referral within the Mount Sinai Health System?

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Yes

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Please select your MSH facility/department:

Who is making the referral (select option that best describes your relationship to the patient):

Does the patient have previous outpatient providers they are planning to return to following discharge from PHP?

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Yes

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In order to place an outpatient referral to PHP, outpatient providers must be willing to accept the patient back following discharge to ensure an effective transition and continuity of care. During PHP admission, the patient's treatment team will work with the patient on preparing to step down and resume outpatient treatment with previous providers upon discharge.

Do you understand and agree to the terms above?

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Yes

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Please provide information on the patient's previous provider and contact information.

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Note: If the patient was hospitalized without established outpatient providers, please indicate and we can assist the patient with after care planning and referral to new care arrangements following discharge from PHP.

Today's date

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M-D-Y

Name of referring provider

* must provide value

Name of referring facility, organization, or practice setting

* must provide value

Email address of referring provider

* must provide value

Phone number of referring provider

* must provide value

Is this an emergency referral?

* must provide value

Yes

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Note: Please consider calling mobile crisis using NYC-WELL, EMS, or direct the patient to the nearest emergency room instead.

Name of patient

* must provide value

Please provide the patient's Mount Sinai MRN

* must provide value

Patient's date of birth

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M-D-Y

Patient's age

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Note: This is an adult PHP serving patients 18 and over. Please direct your referral to a Child and Adolescent program serving patients below 18 years old.

Patient's gender

* must provide value

Does the patient have insurance?

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Yes

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Note: We are unable to accept uninsured patients at this time. We recommend contacting alternative PHP programs who are able to treat individuals who do not have insurance.

If the patient is accepted to PHP, insurance prior authorization must be completed by the referring provider prior to intake. We will provide you with full instructions and necessary information to complete this step.

Do you understand and agree to the terms above?

Yes

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Insurance carrier

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Policy number

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Does the patient have a primary diagnosis of a substance use disorder?

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Yes

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Note: We are only able to accept patients with a primary diagnosis of a defined mental illness with related acute symptoms. Patients who have any co-occurring substance use issues must be able to control symptoms consistent with outpatient safety and collaboratively define related treatment goals.

If you are seeking treatment for a patient primarily addressing addiction to alcohol and substances, please direct your referral to The Addiction Institute of Mount Sinai instead.

Does the patient have an eating disorder or intellectual disability diagnosis?

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Yes

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Note: Please direct your referral to a specialized program focused on addressing this patient's specific needs and treatment goals (ie. eating disorder program, OPWDD, etc.) instead.

Diagnosis

Include differential diagnosis if relevant

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Does the patient have a history of suicide attempts in the past three months? If yes, please provide details.

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Does the patient have a history of violence in the past three months? If yes, please provide details.

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Please provide the patient's medical conditions (if known).

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Anticipated date of discharge (if known)

In a few sentences, please summarize the reasons for the referral. Please state 1. why you feel the patient would benefit from this level of care at this time and 2. why the patient has verbalized interest in PHP vs. other less-intensive treatment options at this time.

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Please summarize the patient's main therapeutic goals.

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Our program involves a high level of commitment to attendance and adherence to the schedule.

Has the patient verbalized understanding and agreed to attend Monday through Friday from 9:30am to 3pm?

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Yes

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Since it is a short-term program, we ask all patients for a 2-week commitment (the longest we are licensed to keep patients enrolled is 6 weeks).

Has the patient agreed to commit to a minimum of 2 weeks?

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Yes

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All patients currently attend 5 groups per day and two 1-hour individual sessions per week during program hours (25 groups and 2 individual sessions per week).

Has the patient verbalized understanding and agreed in participating in treatment where group therapy is the main treatment modality?

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Yes

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Has patient participated in group therapy before?

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Yes

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The program is held in-person and located at Mount Sinai-Harlem Health Center: 158 West 124th Street, New York, NY 10027.

Has the patient verbalized understanding and agreed to commute to Harlem for the duration of the program?

* must provide value

Yes

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Upload the patient's Face Sheet or demographics page

Include patient's phone number, residential address, and email address

* must provide value

Upload file

Upload a copy of the patient's government-issued ID

Not required if submitting Face Sheet

Upload file

Upload a copy of the patient's insurance card (front and back)

Not required if submitting Face Sheet

Upload file

Upload H&P, psychological evaluation, and/or intake assessment

* must provide value

Upload file

Upload patient's admission labs, blood test results, and medication administration report

Include CBC, BMP, EKG, UDS drug tox screening, TSH levels, etc. and anything being monitored during admission (ie. lithium levels)

Upload file

Upload patient's 3 most recent progress notes

* must provide value

Upload file

Upload patient's 3 most recent group notes

Upload file

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