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Samaritan Daytop Village Referral
If this is an emergency, dial 911.
Answer the questions below to provide the information to make a referral
* Which of the following best describes the person making this referral:
Medical/Behavioral Healthcare Provider
Family Member / Significant Other
Other Referral Source
Self
Contact Information for Person Making Referral
* First Name:
* Last Name:
* Preferred Contact Method:
Phone
Email
Email Address:
* Preferred Referral Confirmation Method:
Email
Text
* Carrier Name:
select
Please select a value
Unknown Carrier
Alltel
AT&T
Boost Mobile
Cricket Wireless
FirstNet
Google Fi
MetroPCS
Republic Wireless
Sprint
T-Mobile USA, Inc.
U.S. Cellular
Verizon Wireless
Virgin Mobile
* Mobile Number:
* Phone:
Best Time to Contact:
* Relationship to person being referred:
select
Please select a value
Aunt
Brother
Case Manager
Drug Court Representative
DSS Worker
Father
Judge
Mother
Other
Preventative Worker
Probation Officer
Psychiatrist
Self
Sister
Uncle
Additional Information:
Contact Information for Person Being Referred
* First Name:
* Last Name:
Gender:
Female
Male
Other
* Date of Birth (
MM/DD/YYYY
):
October 2024
October 2024
S
M
T
W
T
F
S
40
29
30
1
2
3
4
5
41
6
7
8
9
10
11
12
42
13
14
15
16
17
18
19
43
20
21
22
23
24
25
26
44
27
28
29
30
31
1
2
45
3
4
5
6
7
8
9
Undomiciled (
does not have a current address
):
Yes
No
Address - Line 1:
Address - Line 2:
City:
State:
select
Please select a value
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Mobile Phone:
Home Phone:
Email Address:
Referral Information
*Is the person (
Self Referral - Are you
) in crisis:
Yes
No
* Does the person require medication? (
You will be asked for a list of medications by your admissions counselor
):
Yes
No
* Type of Services needed:
Mental Health
Substance
Both
*Preferred program location:
select
Please select a value
Bronx
Brooklyn
Dutchess
Manhattan
No Preference
Queens
Rockland
Staten Island
Suffolk
Ulster
Does the person (
Self Referral - Do you
) meet any of the criteria below for priority admission status?:
Intravenous Substance User
Parents in Jeopardy of Losing their Children
Pregnant Intravenous Substance User
Pregnant Substance User
Current Diagnosis:
Yes
No
Unknown
Current Diagnosis Reason:
Current Medical Needs:
Yes
No
Unknown
Current Medical Needs Reason:
Current Medications:
Yes
No
Unknown
Current Medications Reason:
Court Ordered:
Yes
No
Unknown
Court Ordered Reasons:
Additional Information Relating to Referral:
Currently Insured? (
**Samaritan Daytop Village does not deny any clients based on insurance status
):
Yes
No
Unknown
Insurance Information:
Policy Holder:
Please click here or drag or drop files to upload any additional documentation.
All uploads are stored in secure HIPAA compliant location.
Accepted file extensions are: PDF
Current Files:
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