Information on how staff can coordinate with mental health programs and hospitals to improve the health of sheltered or unsheltered clients with serious mental illness
Read the Frequently Asked Questions below to learn more about how each form or resource is used for mental health care coordination.
Shelter Request for Psychiatric Hospitalization. This form can be completed by shelter staff and provided to emergency medical services to advocate for hospital admission if a client is a danger to self or others.
DHS Authorization for Mobile Health Program Accompaniment through Shelter Intake and Placement Form. New or inactive clients with serious mental illness or serious medical issues may need support and encouragement to go through the shelter intake and placement process. Hospitals can coordinate with mobile health programs (ACT, IMT, SOS, ICM, Community Health Workers) to accompany the client through this process. Accompaniment from hospital to shelter helps mobile health programs establish and maintain contact with clients while they are in the shelter system.
Learn more in Frequently Asked Questions 1, 2 and 3.
Shelter Observational Mental Health Assessment. This form can be completed by shelter staff to support SPOA (ACT, IMT, or Care Coordination) applications, or other applications for mental health services.
PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System). Eligible providers can use this platform to review case history to support clinical care coordination, applications for health services such as for ACT, and supportive housing applications.
Learn more in Frequently Asked Question 4.
Learn more in Frequently Asked Question 5.
For sheltered clients:
If a sheltered client is experiencing a behavior health emergency (situation where a person is in immediate danger from themself or another person), call 911.
If the 911 response team determines client should be transported to a hospital, shelters should provide a completed "Shelter Request for Psychiatric Hospitalization" form to EMS staff to provide justification for hospital admission.
If a sheltered client is experiencing behavioral health crisis (time of intense difficulty, distress or trouble), call 988 for a Mobile Crisis Team (MCT), available from 8am to 8pm seven days a week including holidays.
Mobile Crisis Teams arrive within several hours of receiving a referral.
To refer, call 988 or complete the Online Provider and Professional Screening form.
For street homeless clients:
If a street homeless client is experiencing behavioral health crisis, call 311 and request services from "HOMESTAT" (Homeless Outreach Mobile Engagement & Street Action Teams).
Learn more about behavioral health crisis response services in NYC.
Shelter staff should refer clients not engaged in health care* to appropriate health care services:
On-site primary care:
H+H Safety Net Clinics (referral required): Intensive primary care, addiction treatment, care coordination, and resource linkage for people experiencing homelessness with 2 or more chronic health conditions (or medically high risk). Located at Bellevue, Lincoln, Woodhull, and Elmhurst Hospitals. Open Monday to Friday (see schedule for hours)
Virtual urgent care:
H+H ExpressCare (no referral required): Call (845) 397-2273 or visit www.expresscare.nyc/dhs online for medical and behavioral health urgent care and treatment, available 24/7 with no out-of-pocket cost for DHS clients.
Find more health care services, including substance use and harm reduction programs, in the NYC Health Map.
*Examples of not being engaged in health care include: not taking prescribed medication (especially psychiatric medications), not attending scheduled medical appointments, and/or not managing medical condition in coordination with a health care provider.
From hospitals to assigned shelter or safe haven:
All hospital in-patients being referred to DHS single adult facilities must be approved by DHS prior to discharge. Full instructions and required forms for hospitals can be found on the Hospital (Institutional) Referral page.
Training slides for shelters are available here. If the shelter is not sure if the client is medically appropriate for shelter and needs assistance advocating for health services or higher level of care while the client is hospitalized, email: DHS-HCFReferral@dhs.nyc.gov.
From assigned shelter or safe haven to hospitals:
Shelters should work with the hospital as soon as the client is hospitalized to put supports in place to ensure the client will have stable health if they return to shelter, and/or work with the hospital to develop a discharge plan to a higher level of care if needed.
There are several programs in NYC for people with serious mental illness that can benefit from support adhering to psychiatric treatment.
Community- or home-based treatment and support for patients with SMI that are disconnected from mental health services
Assertive Community Treatment (ACT)
Description: Treatment for people with a serious mental illness who have high service needs that are not being met in traditional settings. Includes:
- Shelter Partnered ACT (SPACT) for people who are residents of designated mental health shelters
- Forensic ACT (FACT) for people with current/past criminal justice involvement
Referral process: Online application via NYC DOHMH Single Point of Access (SPOA). A psychosocial evaluation within the last 6 months, or an observational psychiatric evaluation, is required.
Intensive Mobile Treatment (IMT)
Description: For people with serious behavioral health concerns, very complex life situations, transient living situations and/or criminal justice involvement
Referral process: Online application via NYC DOHMH Single Point of Access (SPOA). A psychosocial evaluation within the last 6 months, or an observational psychiatric evaluation, is required.
Court-ordered treatment for patients with SMI with history of psychiatric hospitalizations and physical violence to self/others:
Assistive Outpatient Treatment (AOT)
Court-ordered treatment for people who have difficulty engaging in treatment and poses risk to self/others. Eligibility criteria include history of treatment nonadherence leading to two psychiatric hospitalizations or incarcerations in the last 3 years and history of physical harm to self/others (at least once in the last four years). Based on treatment history and current behavior, eligible patient should be in need of outpatient treatment to prevent a relapse or deterioration likely to result in serious harm to self or others.
More information in the NYC Health Department’s AOT brochure. Call NYC Health Department AOT Program to start the referral process. Clients will often be simultaneously enrolled in IMT, ACT or Care Coordination.
Outreach and care coordination for chronically street or subway homeless patients:
Services include: intensive outreach and engagement, immediate needs resolution (provision of food, clothing, blankets), documentation assistance (helping individuals obtain identification), comprehensive referrals (behavioral health, primary care, social services).
Email referral form (found here) to SOSInfo@cbcare.org,or call 1-866-SOS-4NYC to discuss referral
Supportive housing is a type of permanent rental housing with on-site support services - such as case management, mental health counseling, life skills coaching - in NYC. Populations eligible for supportive housing include people experiencing homelessness with serious mental illness, substance use disorder, or other disabling medical conditions.
The Center for Urban Community Services (CUCS) provides trainings and technical assistance on the Supportive Housing Referral Application.
More information from CUCS about the Supportive Housing Referral Application:
The application is submitted online through the Coordinated Assessment and Placement System (CAPS) system.
Training Slides - Completing a Successful NYC Supportive Housing Application: How to navigate the CAPS system and avoid common problems leading to incomplete applications.
Find more CAPS trainings.