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Referral can be submitted for Respite or Crisis Residence. Please review descriptions below, and choose the appropriate level of care, either column A or column B. Please then choose the specific program within Respite or Crisis Residence, you would like the referral sent.

Respite

A residential setting for adult (18+) consumers to avoid a possible crisis as a result of matters in their current living situation.

Applications are processed Monday-Friday 9am-5pm.

Please choose most appropriate Respite option(s) below:

RiseWell Respite
- Must have address to return to
- Must be independent with medications

FREE Hospital Diversion
- Can be homeless
- Require 24/7 supervision

Concern Respite
- Must have address to return to
- Require 24/7 supervision

Provide Clinical Information

Crisis Residence

A residential setting for consumers who are undergoing a current crisis.

Applications are processed 24 hours a day, 7 days a week.

Please choose most appropriate Crisis Residence option below:
*Select only 1*

Intensive Crisis Residence Program (coming soon)
- Must be experiencing a psychiatric crisis, imminent risk for safety concerns for themselves or others
- Documented mental health diagnosis required

Residential Crisis Support Program
- Must be experiencing symptoms that create imminent risk of impairment of social, emotional or physical functioning and do not pose imminent risk to the safety of themselves or others
- A mental health diagnosis is not necessary for this service

Clinical Information is NOT required

Supporting Documentation

Upload file

Individual has been informed that this is a voluntary program and is not an offer of housing

Yes

Personal Information

First Name

Last Name

Date Of Birth

Gender

Please check if you would like to receieve email updates regarding this application

Applicant's Email

Applicant's Alternate Email

Family Information

MaritalStatus

Name of Spouse/Domestic Partner

Phone of Spouse/Domestic Partner

Name of Legal Guardian

Phone of Legal Guardian

List children of individual:

Does the individual have Custody of Children

Yes

Has Child care been arranged in the individual’s absence

Yes

Housing Information

Address

City

State

Zip

Housing Type

Primary Phone

OK to Leave Message?

Yes

What is the housing plan, post-discharge?

DSM-V Diagnosis, Daily Activities and Service Animal Information

DSM-V Diagnosis

Day Activities:

Work

PROS

Volunteer

School

Other

Has transportation arranged

Yes

Is the individual currently receiving treatment from a licensed professional

Yes

Service Animal Information

Does the individual have a service animal

Yes

Is there documentation

Yes

High-Risk Behavior Information

High Risk Behavior (any MH symptoms that need to be monitored):

Yes

If yes, please explain

Additional Risk Factors:

Animal Cruelty

Delusions

Hallucinations

Fire Setting

Gang Involvement

Inappropriate Sexual Behavior - Acting Out

Manic behavior

Self Injurious Behavior

Eating Disorder

Panic/Anxiety

Depression

Victim of:

Physical Abuse

Domestic Abuse

Emotional Abuse/Physical Neglect

Sexual Abuse

Substance Use Information

Is the Individual a Substance User

Yes

If yes, please explain

Date & reason for most recent psychiatric hospitalization (if applicable):

Why does the individual feel a respite would be beneficial?

Current Suicidal/Homicidal Ideation/Recent Suicide Attempt/Self Injurious Behavior:

Previous History of Suicidal/Homicidal Ideation/Attempt/Self Injurious Behavior:

Brief Psychiatric/Substance/Physical Health Current Status History:

Any History of Violence:

Medical Information

Medical/Physical Health, Current Status and History

Does the Individual have allergies (include medications)

Yes

If yes, please list

List all medications currently taken, including frequency, amount, and name of medicine:

Does the Individual need assistance to monitor their own medications

Yes

Does the Individual have at least a 30 day supply of Medication

Yes

Does the Individual have upcoming appointments

Yes

If yes, please list

Does the Individual require 24 hour supervision

Yes

Other Information

Does the individual have Mobility issues

Yes

If yes, please explain:

Does the individual have Special Needs (i.e: Dietary Needs)

Yes

If yes, please explain:

Require assistance with ADL’s

Yes

If yes, please explain:

Any legal history/aggression/assault:

Yes

If yes, please list:

Individual is Involved With:

AOT

ACT

Probation

Parole

Previous Incarceration

Individual's Support Information

Primary Contact Name:

Relationship:

Phone:

Address:

City:

Zip:

Psychiatric/Mental Health Provider

Psychiatric/Mental Health Provider Name:

Psychiatric/Mental Health Provider Agency:

Psychiatric/Mental Health Provider Phone:

Psychiatric/Mental Health Provider Address:

Psychiatric/Mental Health Provider City:

Psychiatric/Mental Health Provider Zip:

Therapist Information

Therapist Name:

Therapist Agency:

Therapist Phone:

Therapist Address:

Therapist City:

Therapist Zip:

Housing Provider Information

Housing Provider Name:

Housing Provider Contact Name:

Housing Provider Phone:

Housing Provider Address:

Housing Provider City:

Housing Provider Zip:

Care Coordinator Information

Care Coordinator Name:

Care Coordinator Agency:

Care Coordinator Phone:

Care Coordinator Address:

Care Coordinator City:

Care Coordinator Zip:

Medical Provider Information

Medical Provider Name:

Medical Provider Phone:

Medical Provider Address:

Medical Provider City:

Medical Provider Zip:

Additional Contact 1

Additional Contact Name:

Additional Contact Relationship:

Additional Contact Phone:

Additional Contact 2

Additional Contact 2 Name:

Additional Contact 2 Relationship:

Additional Contact 2 Phone:

Insurance Information

Primary Insurance:

Group Number:

Medicaid Number:

Medicare Number:

Secondary Insurance:
Does the Individual receive Food Stamps

Yes

Does the Individual need to apply for Food Stamps

Yes

Does the Individual receive Public Assistance

Yes

Does the Individual receive SSI

Yes

Does the Individual receive SSD

Yes

Does the Individual need to apply for public assistance

Yes

Does the Individual have an active SPA application submitted

Yes

Has the Individual been in a Crisis Respite Recently?

Yes

If Yes, what agency:

Referral Information

Are you referring yourself for respite/crisis residence? (Self-referral)

Referral Source (Agency/Program)

Referral Name

Referral Address

Referral Phone

Referral Email Check if you would like to receieve email updates

Referral Reason

Consent for Service

By checking the box below, the individual completing the application attests that consent has been received by the referred individual, or legal guardian. Additionally, the referred individual acknowledges the services sought are affiliated with the Suffolk County Division of Community Mental Hygiene.

I attest that consent has been received by the referred individual, or legal guardian.

Attestation Name:

Attestation Relationship:

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