MAS New York Social Services Department Referral Form

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Thank you for reaching out to us! Below you will find a few questions asking you for contact information as well as what you are reaching out for services for. This will aid us in referring you directly to the appropriate person and service. Information will be kept confidential and only used for the purposes of referral.

DISCLAIMER - If this is an emergency, please contact 911 as we take up to 3 to 5 days to respond to requests for help finding services through this form.

Name *

Age *

Gender *

Male

Female

Prefer not to say

Contact Number *

Contact Email *

Best time to call? *

Morning

Afternoon

Evening

Do you have insurance? *

Yes

Would you like individual, couples, or family therapy? *

Individual

Couples

Family

I do not want therapy

What is your reason for reaching out to the social services department, and what would you like us to assist you with? *

Submit

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