• 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: 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.
• Serious mental illness including psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder, major depression and post-traumatic stress 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.
• Serious mental illness including psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder, major depression and post-traumatic stress disorder are most appropriate for SPOA referrals.

• Description: Critical Time Intervention (CTI) is a 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 at H+H Bellevue, Jacobi, Kings County, Metropolitan and Queens Hospital, among other health care facilities

Description: For individuals transitioning from inpatient psychiatric care to the community. Provides day-of-discharge support and accompaniment, linkage and accompaniment to behavioral health/medical appointments, family conferences, benefits and entitlement support, housing assistance, enrollment in case management and other services. 

To refer patients: Email the CBC referral form to CBC Pathway Home; see the Pathway Home website for referral forms and instructions. 

Several organizations operate specialized forensic intensive case management and re-entry services across the boroughs:

• CASES (Center for Alternative Sentencing and Employment Services): Offers Forensic Homeless Intensive Case Management (FHICM) for individuals returning from state prison and provides holistic, community-based care.
• EAC Network: Operates the Brooklyn and Staten Island Forensic LINK programs, which provide alternative-to-incarceration and re-entry case monitoring.
• RISE Housing and Support Services: Runs a dedicated FICM program designed to assist justice-involved individuals in managing their mental health and navigating the legal system.

• Description: For individuals experiencing unsheltered homelessness, including living on the streets or public transit, who need persistent outreach and support. Intensive street and transit outreach, identification/document assistance, behavioral health/primary care linkage, referrals for benefits/legal/employment/social services, housing navigation and placement. 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 the CBC referral form to CBC Safe Options Support; see the CBC SOS website for referral forms and instructions. 
  

• Description: Care management services for high-need Medicaid-eligible people with serious mental illness
• Apply through your Medicaid Managed Care Program

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.
• Serious mental illness including psychotic disorder (schizophrenia, schizoaffective disorder), bipolar disorder, major depression and post-traumatic stress disorder are most appropriate for SPOA referrals.

• 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. 

NYC Health Justice Network pairs people returning home from incarceration with Community Health Workers (CHWs) with lived experience of successful reentry from the criminal legal system. CHWs provide social emotional support, health navigation, and linkage to social services and legal support.

To refer patients: Email the completed contact form to NYCHJN@health.nyc.gov.

• Description: Lighthouse Guild offers safe mobility trainings to people who are visually impaired. These include: techniques for walking safely at home (including shelter), on the street and in public transit; how to use the long, white cane for independent travel.
• How to refer: Submit the online request form for group or one-on-one sessions.

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