• If the individual has severe mental illness and is a chronic danger to self or other but lacks insight into their condition and declines mental health services, a referral can be submitted without patient consent and the program will outreach and attempt to engage in services over time. Please loop DHS into the referral to help advocate for expedited enrollment.
• Programs that may be able to take clients more quickly include: Shelter Partnered ACT, Health Homes/Care Coordination, and Safe Options Support.

• Description: Care management service for adults with SMI who need transition in care (e.g. discharge from inpatient psychiatric long-stay/multiple admissions; discharge from ER/CPEP/other crisis services)
• To refer patients: Internal referrals only at H+H Bellevue, Jacobi, Kings County, Metropolitan and Queens Hospital

Description: Treatment for people with SMI and high service needs not being met in traditional settings. People with SMI who are otherwise unable to connect to community treatment can receive clinical support from an interdisciplinary team, including medication management, behavioral health therapy, assistance with supportive housing applications, and advocacy for hospitalization.

• Shelter Partnered ACT (SPACT) for people assigned to designated mental health shelters
• Forensic ACT (FACT) for people with current/past criminal justice involvement 

To refer patients:

• Online application via NYC DOHMH’s Mental Health Single Point of Access (SPOA). A psychiatric and psychosocial evaluation are required.

• For DHS clients only: if a psychiatric evaluation is not available, an observational mental health assessment can be submitted.
• Psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder and post-traumatic disorder are most appropriate for SPOA referrals.

Description: For people with serious behavioral health concerns, very complex life situations, transient living situations and/or criminal justice involvement.

To refer patients:

• Online application via NYC DOHMH’s Mental Health Single Point of Access (SPOA). A psychiatric and psychosocial evaluation are required.

• For DHS clients only: if a psychiatric evaluation is not available, an observational mental health assessment can be submitted.
• Psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder and post-traumatic disorder are most appropriate for SPOA referrals.

Description: Care management services for high-need people with serious mental illness not eligible for Medicaid, including people with SMI not eligible for Medicaid waitlisted for ACT or IMT. 
(Clients eligible for Medicaid should enroll in Health Homes Plus/Health Homes.) 

To refer patients:

• Online application via NYC DOHMH’s Mental Health Single Point of Access (SPOA). A psychiatric and psychosocial evaluation are required.

• For DHS clients only: if a psychiatric evaluation is not available, an observational mental health assessment can be submitted.
• Psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder and post-traumatic disorder are most appropriate for SPOA referrals.

Description: Provides day-of-discharge support and accompaniment, accompaniment to medical appointments, family conferences, benefits and entitlement support, expedited housing placement, enrollment in long-term case management services and other services. Learn more 

To refer patients: 

• Submit Pathway Home referral package.
• Contact PathwayHomeInfo@cbcare.org or (646) 930-8841 for questions. 

• Description: Care management services for high-need Medicaid-eligible people with serious mental illness

• Description: Outreach and care coordination for patients experiencing street/subway homelessness. Services include: outreach and canvassing; assistance enrolling in housing/employment assistance, benefits, legal services; linkage to medical care, including substance use and behavioral health treatment. Learn more
• To refer patients: If client has a recent history of street or subway homelessness and is unlikely to enter shelter, refer to SOS. Email referral form to SOSInfo@cbcare.org, or call 1-866-SOS-4NYC to discuss referral

• Description: Integrated primary care, addiction treatment and behavioral health care, care coordination, and linkage to specialty care for people with multiple chronic health conditions who are experiencing homelessness
• To refer patients: Safety Net Clinic contact information for patient referrals 

• Mobile clinic for health screenings and referrals; medical care, behavioral health resources, harm reduction, and material goods to people who are unsheltered or living on the street. Learn more
• Refer through Safety Net Clinic referral contacts 

• Description: People enrolled in a Health Home are assigned a care manager who will develop a care plan and connect enrollees to health care providers, behavioral health providers, medications, housing and social services. Eligible patients must have or more chronic conditions or one single qualifying chronic condition (HIV/AIDS, serious mental illness, sickle cell disease). Learn more 
• To refer patients: Contact a Health Home in the patient's borough of residence. To determine patient's borough of residence, contact the DHS Institutional Referral Program. Some Health Homes can accommodate multiple boroughs of residence. 

To refer patients: Home care agencies can be found on the NYS Department of Health website.