One Medical - NAMI NYC Rapid Referral
First and last name of the person being referred: *
Your answer
Telephone number of the person being referred: *
Your answer
This person’s relationship to the person living with a mental health condition: *
Best time to call: *
Required
Preferred language *
I give permission to my healthcare or other service provider to give my name, contact information, and protected health information to NAMI NYC. I understand that a NAMI NYC Helpline volunteer or staff person will contact me about the free support and educational services that are available. I understand that my name, contact information and other information listed below will not be disclosed or shared with any other entity unless authorization is obtained by me. I understand that I can revoke my permission at any time by contacting the referring provider named below. I give permission to NAMI NYC to follow up with the provider named below.
Electronic signature *
Required
TO BE COMPLETED BY REFERRING PROVIDER
Provider First and Last Name: *
Your answer
Provider Organization: *
Your answer
Provider Phone: *
Your answer
Provider Email: *
Your answer
Reason for referral: (please check all that apply):
Date *
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This form was created inside of National Alliance on Mental Illness of New York City. Report Abuse - Terms of Service