Crisis Respite Center
Referral Packet Checklist
*Please do your best to fill out this packet completely and legibly. This will save time so
we won’t have to follow up regarding missing information, and can move forward with
approving the application.
Once completed, please send back via fax or email at:
Fax: 212-614-1413
Email: [email protected]
 Facesheet: All fields Fully Completed
 Crisis Respite Center Enrollment Form: Must be filled out by person being
referred and a licensed provider, complete with answers from person being
referred and license number of provider recorded; signed and dated
 Post Discharge Placement Plan: Completely filled out including the address
where the person being referred will discharge to, and a backup address should
their plans fall through; signed and dated
 Medication List: Filled out completely including record of substances used in
the last week, and the last 6 months
 Insurance Provider Consent Form: Completed, signed and dated
 Referral Source Consent Form: Completed, signed and dated
*Please Print all Information Legibly*
Referral Information-Respite Center
1. Name (Last, First, Middle):
Community Access
Referral Sent Date and Time:
2. Also Known As:
4. Age:
3.Gender Identity and pronoun
preference:
7. Address (No., Street, City, State, ZIP Code):
5. D.O.B.:
6.Email Address:
8. Phone:
Alt. Phone:
Ok to leave VM? Y or N
10. Veteran Status:
Y or N
12. A. Source of Income
9. Type of Housing (TAP, With Family, Friends, Residential Program, Own Apt, etc)
11. A. What ethnic background do you identify with:
□ Employment
□ SSI
□ SSD
□SSA
□TANF
□VA Benefits
□Other
□None
B. Primary Language:
13.Social Security #:
14.Medicaid #:
15. Medicare # or private insurance if applicable:
16. Managed Care Company :
17. Emergency Contact information:
A. Name:_____________________________ B. Relationship:_____________________________
B. Amount of Income:
C. Phone:_____________________________ D: Address: _______________________________
________________________
$
/Month
(Please write Guest Declined if one is not provided at intake)
18. Referral Source: (if self-referral please check here □ and write the information for who will
complete the enrollment form, Please note: they must be a licensed provider )
A. Name:_____________________________ B. Title:___________________________________
C. Phone:_____________________________ D: Agency: _______________________________
E. Fax:_______________________________
F. E-mail: _______________________________
E. Address:______________________________________________________________________
20. Psychiatrist:
19. Employment Status:
□ Full-Time Employment
(35 hours or more)
□ Part-Time Employment
□ Internship (Paid/Stipend
or Unpaid)
□ Volunteering
□ None
A. Name:_____________________________ A. Agency:____________________________
21. Citizenship Status:
□ U.S. Citizen
□ Registered Non-Citizen
C. Phone:_____________________________ D: Address: ______________________________
□ Unregistered Non-Citizen
22. Physician:
23. A. Health Conditions:
(Green Card)
(Diabetes, Hypertension, etc.)
A. Name:_____________________________ A. Agency:____________________________
C. Phone:_____________________________ D: Address: ______________________________
B: Allergies + reaction:
24. Substance Use: (please list all including Alcohol, Tobacco and medications not prescribed)
Used in Last Week:__________________________ In last 6 Months:___________________________
25. Able to independently:
Able to refrain from using substances of alcohol onsite during the entire respite stay? Yes
No Unsure
COMMUNITY ACCESS USE ONLY
Received and Reviewed Date and Time: ________________
□ Enrollment Form □ Post Placement
□ Face sheet
□ Medication List
Follow Up Call To Guest Date and Time:________________ Placed by:________________________
Eligibility Status: □ APPROVED □ HOLD (further info needed/Admin Review) □INELIGIBLE
Scheduled Bed Date/time:______________ Confirmed with:_____________ Date/Time:___________
□ Care for hygiene
□ Clean up after oneself
□ Prepare meals
Special care or assistance
needed:
NYC
Crisis Respite Center
Enrollment Form
Overview
The NYC Crisis Respite Centers ( formerly known as Parachute NYC) serve people anticipating or experiencing a
mental/emotional health crisis, providing a temporary residential stay in a warm, safe, and supportive home-like
environment. The Centers offer 24/7 support, by Peers, or individuals with lived experience with mental health issues, as
well as Behavioral Health Professionals. The Respite Centers provide an innovative and unique alternative and/or
complementary service to more traditional emergency room and inpatient care. Individuals referred to Crisis Respite
Centers may be enrolled the same day, pending bed availability, and may stay for a period of 1-7 days.
During a stay at a Crisis Respite Center, individuals are encouraged to continue meeting with their treatment provider(s).
Treatment providers, family members, and others that are part of a person’s support network, are welcome to come to the
Respite Center to provide additional support. With the individual’s consent, collaboration between Crisis Respite Center
staff and an individual’s treatment provider(s) is welcomed.
To find out more information about NYC respites, visit our website at:
http://www.nyc.gov/html/doh/html/mental/parachute.shtml
Or contact a Crisis Respite Center directly (Individuals generally stay within their borough of residence.
Residents of Staten Island may utilize any Crisis Respite Center):
Manhattan – Ph#: (646) 257-5665 Fax#:(212) 614-1413
Brooklyn – Ph#: (347) 505-0870 Fax#: (877) 603-5170
Date of Referral:
DOB:
Queens – Ph#: (718) 464-0375
Bronx – Ph#: (718) 884-2992
Fax#: (718) 217-2366
Fax#:(718) 884-2901
Name of Person Being Referred:
Contact # for Person Referred:
The questions below should be answered by the potential crisis respite center guest:
(Questions may be completed at point of enrollment)
1. Please indicate your reasons for seeking a stay at the Crisis Respite Center:
Click here to enter text.
2. Please indicate what you expect/hope to obtain from your stay at the Crisis Respite Center?
Click here to enter text.
3. Please indicate any strengths you have that may help both you, and the staff at the Crisis Respite Center,
manage your current emotional crisis?
Click here to enter text.
______________________________
Signature of Potential Guest
Date
1
Name of Person Being Referred: ___________________________
The questions below should be answered by the referring provider:
Eligibility Criteria and Considerations for Enrollment:
1. Is the person being referred experiencing emotional/mental distress or crisis?
o ☐Yes
☐No
2. Is a resident of New York City?
o ☐Yes
☐No
3. Is 18 years or older?
o ☐Yes
☐No
4. Has a safe and reliable place to return to upon conclusion of stay (this may be a shelter)?
o ☐Yes
☐No
5. Is in stable physical health (including not in need of inpatient detoxification services)?
o ☐Yes
☐No
6. Has the ability to manage his/her own medication independently, if he/she chooses to take medications
(medications are not dispensed at Crisis Respite Centers)?
o ☐Yes
☐No
☐N/A
7. Is a voluntary enrollee (Individual must choose to participate in Crisis Respite services)?
o ☐Yes
☐No
8. Does the person being referred have a history of violence within the last 30 days? Individuals with a
history of violence within the last 30 days will still be considered on a case-by-case basis.
o ☐Yes
☐No
9. Has a diagnosis of serious mental illness or probable diagnosis of a serious mental illness (such as
schizophreniform disorder or psychosis (NOS)?
o ☐Yes
☐No
Diagnosis: __________________________________
`
___________________________________
___________________________________
10. Is the potential guest HARP (Health and Recovery Plan) enrolled?
☐Yes
☐No
The Crisis Respite Centers currently cannot enroll individuals who are at imminent risk to themselves or
others; are diagnosed with dementia, organic brain disorder or traumatic brain injury (TBI); and are
unable to navigate 2 flights of stairs.
1. Is the person being referred at imminent risk to themselves or others?
☐Yes
☐No
2. Does the person have a diagnosis of dementia, organic brain disorder or traumatic brain injury (TBI)?
☐Yes
☐No
3. Is the person able to navigate 2 flights of stairs?
☐Yes
☐No
With my signature below, I attest that the individual being referred meets the indicated enrollment criteria, and
would benefit from a stay at a Crisis Respite Center.
Provider Name:
Signature:
Date:
Phone:
Email:
License Number:
Fax:
**While not required for enrollment, any additional documents (such as most recent psychosocial or psychiatric
evaluation), may be sent with this enrollment form and are appreciated. Thank you for your referral .
Name: ________________________
Date: __________
Post Discharge Placement Plan
The Respite center offers up to 7 days of service to assist individuals experiencing a crisis related to their mental health.
It is requested that all individuals have a reasonable and safe discharge plan prior to admission. Upon discharge the
Respite is unable to provide housing, though we have information available regarding shelters and drop-in centers.
Please describe where you will be relocating to after your stay at the respite is complete. Please include the address if
known, name(s) of anyone you might be staying with, or name of shelter, drop-in center, or other transitional housing
service you plan to discharge to.
1) A)I have housing and will be discharging back to my current residence at:
________________________________________________________________
B)This housing is: □my own apt □with family /friends □supportive housing □ other _________________
2) I have housing but will be discharging to a different location at and with:
________________________________________________________________
I do not have housing. I plan to discharge to:
________________________________________________________________
3) The status of plan stated above is (circle one):
Confirmed
Location Confirmed but the date I can move-in is still unknown
A location I will refer to the day of discharge
Not confirmed
4) If my plans for discharge as listed above fall through, I will utilize the following back-up plan and location upon
discharge:
___________________________________________________________________________________________
___________________________________________________________________________________________
5) The following individuals are assisting with my discharge planning and should be involved:
Name:______________________________
Phone:_______________
Name:______________________________
Phone:_______________
6) I agree that this plan is accurate and that if any changes are made I will notify Respite staff immediately with my new
plan of discharge.
Guest Signature:______________________________
Date:________________
Guest Name:________________________
Date:_____________
Respite Worker:_____________________
The following is a list of medications I currently take, recorded to the best of my ability:
Name of Medication
EXAMPLE MED-GUM
Dosage (mg,
ml, etc)
20mg
Frequency
Quanity
Twice daily
2 tablets
Start Date
(if known)
12/13/12
Side effects experienced:
None
SUBSTANCE USE (Please list all substances used including, alcohol, tobacco, and medications you are not prescribed)
Substances used in last week:________________________________________________________________________________________
Substances used in last 6 months:_____________________________________________________________________________________
COMMUNITY ACCESS, INC.
INDIVIDUAL AUTHORIZATION
Name of Program Participant: ____________________________________________________________
We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this
commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This
form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the
information below carefully before signing this form.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
A representative of Community Access, Inc. must answer these questions completely before providing this authorization form to you. DO NOT SIGN A BLANK
FORM. You or your personal representative should read the descriptions below before signing this form.
Who will disclose the information? The person(s) or class of persons authorized to disclose the information are described below.
The Crisis Respite Center
________________________________________________________________________________
________________________________________________________________________________
Who will use and/or receive the information? The person(s) or class of persons authorized to use and/or receive the information are described below.
My Insurance Provider
________________________________________________________________________________
________________________________________________________________________________
What information will be used or disclosed? The appropriate boxes should be checked below and the descriptions should be in enough detail so that you (or
any organization that must disclose information pursuant to this authorization) can understand what information may be used or disclosed.
x
The following information:
Information collected on referral documents and reasons for seeking respite
_____________________________________________________________________________
_______________________________________________________________________
The following HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related
illness or AIDS, or any information which could indicate that you have been potentially exposed to HIV):
_____________________________________________________________________________
_______________________________________________________________________
What is the purpose of the use or disclosure? The purposes for which the information will be used or disclosed are described below. The words “at the
request of the individual” is a sufficient description of the purpose when a program participant initiates the authorization and chooses not to provide any further
explanation of the purpose.
At the request of the individual
___________________________________________________________________________________
_____________________________________________________________________________
How often will use or disclosure be allowed, and when will this authorization expire?
The appropriate box should be checked below to determine how often use or disclosure will be allowed, and the date or the event that will trigger the expiration of
this authorization.
A.
One-Time Use/Disclosure. This authorization hereby permits the one-time use or disclosure of the information described above to the person(s) or
class of persons identified above.
This authorization will expire:
When acted upon;
90 days from this date;
Other _________________________________________________________________________________________________ ______
B.
Periodic Use/Disclosure. This authorization hereby permits the periodic use or disclosure of the information described above to the person(s) or class
of persons identified above.
This authorization will expire:
When I am no longer receiving services from Community Access;
One year from this date;
Upon my discharge from The Crisis Respite Center
x Other _______________________________________________________________________________________________________
S:\OMH\OMH Housing\03.- 04. Privacy\03. CA Individual Authorization final 04.03.doc
SPECIFIC UNDERSTANDINGS
By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be
redisclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by
federal health information privacy regulations.
If you are authorizing the release of HIV-related information, you should be aware that the recipient(s) is prohibited from redisclosing any HIV-related information
without your authorization unless permitted to do so under federal or state law. You also have a right to request a list of people who may receive or use your HIVrelated information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the
New York State Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are
responsible for protecting your rights.
You have a right to refuse to sign this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do
not sign this form.
You also have a right to receive a copy of this form after you have signed it.
If you sign this authorization, you will have the right to revoke it at any time, except to the extent that Community Access, Inc. has already taken action based upon
your authorization. To revoke this authorization, please contact a manager of your program.
SIGNATURE
I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above.
x
__________________________________________________
Signature of Program Participant or Personal Representative
x
__________________________________________________
Print Name of Program Participant or Personal Representative
x__________________________________________________
Date
__________________________________________________
Description of Personal Representative’s Authority
CONTACT INFORMATION
The contact information of the program participant or personal representative who signed this form should be filled in below.
Address:
Telephone:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
________________________ (daytime)
________________________ (evening)
Email Address (optional):
______________________________
THE PROGRAM PARTICIPANT OR HIS OR HER PERSONAL REPRESENTATIVE MUST BE PROVIDED WITH A COPY OF THIS FORM AFTER IT HAS BEEN SIGNED.
REVOCATION OF AUTHORIZATION
I hereby revoke my authorization to use/disclose the information described above to the person(s) or class of persons identified above.
__________________________________________________
Signature of Program Participant or Personal Representative
__________________________________________________
Print Name of Program Participant or Personal Representative
__________________________________________________
Date
__________________________________________________
Description of Personal Representative’s Authority
COMMUNITY ACCESS, INC.
INDIVIDUAL AUTHORIZATION
Name of Program Participant: ____________________________________________________________
We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this
commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This
form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the
information below carefully before signing this form.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
A representative of Community Access, Inc. must answer these questions completely before providing this authorization form to you. DO NOT SIGN A BLANK
FORM. You or your personal representative should read the descriptions below before signing this form.
Who will disclose the information? The person(s) or class of persons authorized to disclose the information are described below.
Referring Clinician
________________________________________________________________________________
________________________________________________________________________________
Who will use and/or receive the information? The person(s) or class of persons authorized to use and/or receive the information are described below.
Community Access Crisis Respite Center
________________________________________________________________________________
________________________________________________________________________________
What information will be used or disclosed? The appropriate boxes should be checked below and the descriptions should be in enough detail so that you (or
any organization that must disclose information pursuant to this authorization) can understand what information may be used or disclosed.
x
The following information:
That which relates to my clinical care as needed to support my referral
_____________________________________________________________________________
admission and stay at the Crisis Respite Center.
_______________________________________________________________________
The following HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related
illness or AIDS, or any information which could indicate that you have been potentially exposed to HIV):
_____________________________________________________________________________
_______________________________________________________________________
What is the purpose of the use or disclosure? The purposes for which the information will be used or disclosed are described below. The words “at the
request of the individual” is a sufficient description of the purpose when a program participant initiates the authorization and chooses not to provide any further
explanation of the purpose.
At the request of the individual
___________________________________________________________________________________
_____________________________________________________________________________
How often will use or disclosure be allowed, and when will this authorization expire?
The appropriate box should be checked below to determine how often use or disclosure will be allowed, and the date or the event that will trigger the expiration of
this authorization.
A.
One-Time Use/Disclosure. This authorization hereby permits the one-time use or disclosure of the information described above to the person(s) or
class of persons identified above.
This authorization will expire:
When acted upon;
90 days from this date;
Other _________________________________________________________________________________________________ ______
B.
Periodic Use/Disclosure. This authorization hereby permits the periodic use or disclosure of the information described above to the person(s) or class
of persons identified above.
This authorization will expire:
When I am no longer receiving services from Community Access;
One year from this date;
Upon my discharge from the Crisis Respite Center
x Other _______________________________________________________________________________________________________
S:\OMH\OMH Housing\03.- 04. Privacy\03. CA Individual Authorization final 04.03.doc
SPECIFIC UNDERSTANDINGS
By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be
redisclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by
federal health information privacy regulations.
If you are authorizing the release of HIV-related information, you should be aware that the recipient(s) is prohibited from redisclosing any HIV-related information
without your authorization unless permitted to do so under federal or state law. You also have a right to request a list of people who may receive or use your HIVrelated information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the
New York State Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are
responsible for protecting your rights.
You have a right to refuse to sign this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do
not sign this form.
You also have a right to receive a copy of this form after you have signed it.
If you sign this authorization, you will have the right to revoke it at any time, except to the extent that Community Access, Inc. has already taken action based upon
your authorization. To revoke this authorization, please contact a manager of your program.
SIGNATURE
I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above.
x
__________________________________________________
Signature of Program Participant or Personal Representative
x
__________________________________________________
Print Name of Program Participant or Personal Representative
x
__________________________________________________
Date
__________________________________________________
Description of Personal Representative’s Authority
CONTACT INFORMATION
The contact information of the program participant or personal representative who signed this form should be filled in below.
Address:
Telephone:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
________________________ (daytime)
________________________ (evening)
Email Address (optional):
______________________________
THE PROGRAM PARTICIPANT OR HIS OR HER PERSONAL REPRESENTATIVE MUST BE PROVIDED WITH A COPY OF THIS FORM AFTER IT HAS BEEN SIGNED.
REVOCATION OF AUTHORIZATION
I hereby revoke my authorization to use/disclose the information described above to the person(s) or class of persons identified above.
__________________________________________________
Signature of Program Participant or Personal Representative
__________________________________________________
Print Name of Program Participant or Personal Representative
__________________________________________________
Date
__________________________________________________
Description of Personal Representative’s Authority