How to Fill Out and Submit the NYC Respite Referral Form

To request a short-term stay at one of New York City’s crisis respite centers, download the NYC Respite Referral Form as a PDF from the Department of Health and Mental Hygiene website, fill out all four sections, and bring, fax, or email it to the respite center you want to stay at.1NYC Health. Crisis Services/Mental Health: Residential Crisis Support and Respite Centers Walk-ins are accepted too if you need help right away and haven’t completed the form in advance.

Check That You’re Eligible Before You Start

The form itself screens for eligibility, so it helps to know the gates before you fill in a single line. To qualify, all of the following need to be true:

  • You are 18 or older.
  • You are a New York City resident.
  • You are experiencing or anticipating a psychiatric or emotional crisis that cannot be managed well in your current environment.
  • Your stay is voluntary, and you do not have a court order for Assisted Outpatient Treatment. The form asks this directly, and a court order makes you ineligible.2New York City Department of Health and Mental Hygiene. NYC Residential Crisis Support and Respite Referral Form
  • You are medically stable and can handle eating, bathroom use, and taking your own prescribed medications without assistance.
  • You are not at imminent risk of hurting yourself or someone else. If you are, call 988 or go to an emergency room; respite centers are not set up for that level of crisis.

Insurance is not a gate. The form asks for your insurance details only “if available,” so uninsured applicants should leave those fields blank and move on.2New York City Department of Health and Mental Hygiene. NYC Residential Crisis Support and Respite Referral Form

Filling Out the Form, Section by Section

The form is one page, split into four parts. Complete every field you can. Blank spots don’t disqualify you, but they slow intake and sometimes send a form to the bottom of the pile.

Referral Information

Enter today’s date at the top and check the box that describes how the referral is being made. Options include self-referral, managed care plan, inpatient mental health, emergency department, mobile crisis team, 988, family or friend, outpatient mental or behavioral health, care coordination, the NYC Department of Homeless Services, and others. If you are filling the form out for yourself, check “Self-referral.”2New York City Department of Health and Mental Hygiene. NYC Residential Crisis Support and Respite Referral Form

Potential Guest Information

This part collects who you are and how to reach you. Fill in your preferred name (what you want to be called), your legal first and last name, and your date of birth. Check “Yes” to confirm you are 18 or older and an NYC resident. Add your current address or location, your preferred language, and at least one phone number. Include an email if you have one so staff have a second way to reach you.

Then list your insurance provider and policy ID if you have coverage. Leave it blank if you don’t. Finally, give the name, relationship, and phone number of an emergency contact if one is available.

Clinical and Assessment Information

This is the section that drives the admission decision, so take your time with it.

First, describe your current crisis in your own words. Specifics help. “I haven’t slept in four days and I’ve been having daily panic attacks since losing my housing” tells the intake team far more than “I’m stressed.” Say what is happening and why your home or current environment is not a workable place to ride it out.

Next, fill in the brief wellness and recovery plan. There is room for up to nine numbered items. Treat them as goals or steps you’d like to work on during your stay, in plain language.

Then check what you are hoping a short-term crisis support program will do for you. The options are “Prevent hospitalization,” “Receive peer support,” and “Other.”

The rest of the section is a set of yes-or-no screening questions:

  • Is the guest experiencing a crisis that can’t be managed at home?
  • Is the guest at imminent risk of hurting themselves or others?
  • Does the guest have a court order for Assisted Outpatient Treatment?
  • Is the guest medically stable?
  • Does the guest have significant medical conditions or allergies?
  • Can the guest handle personal needs independently?
  • Does the guest need on-site accommodations such as wheelchair access?
  • Does the guest have a safe place to return to after their stay, or are they willing to go to a shelter if needed?

Answer honestly. “Yes” to imminent risk or to a court-ordered treatment mandate will route you elsewhere rather than into a respite bed. If you have medical conditions or allergies, list them in the space provided so staff can plan around them.2New York City Department of Health and Mental Hygiene. NYC Residential Crisis Support and Respite Referral Form

Referral Provider Information and Signatures

If a clinician, case manager, or other provider is making the referral for you, they complete this section with their name, credentials (such as LCSW, LMHC, or MD), agency name, and contact information. If you’re self-referring, leave the professional credential fields blank, write your own name, and put “self” as the relationship. Both the referral contact and the potential guest sign and date the bottom.

How to Submit the Completed Form

You have three ways to get the form to a center:

Submitting the form does not guarantee a bed. The form itself notes that admission is decided case-by-case and depends on availability.2New York City Department of Health and Mental Hygiene. NYC Residential Crisis Support and Respite Referral Form If a center is full, ask about the waitlist or try another borough. There are eleven centers across the city, and openings move around.

Where to Send the Form: Respite Centers by Borough

Each center operates under contract with DOHMH. Contact details and bed counts come from the referral form and the DOHMH listing.1NYC Health. Crisis Services/Mental Health: Residential Crisis Support and Respite Centers

Bronx

Brooklyn

  • Services for the Underserved (Brooklyn Respite), 2118 Union Street, Brooklyn, NY 11212. Phone (347) 505-0870. Fax (877) 603-5170. 10 beds.
  • Services for the Underserved (Bright Corner), 17–19 Montrose Avenue, Brooklyn, NY 11206. Phone (646) 757-4561. Fax (877) 603-5170. 3 beds.
  • Ohel Children’s Home and Family Services, 1664 41st Street, Brooklyn, NY 11218. Phone (800) 603-6435. Fax (718) 686-4250. 3 beds.
  • TownHome Kings Respite, 3402 Clarendon Road, Brooklyn, NY 11203. Phone (718) 473-9860. Fax (877) 341-4347. 11 beds.

Manhattan

  • Community Access, 315 Second Avenue, New York, NY 10003. Phone (646) 257-5665 ext. 8401. Fax (212) 614-1413. 8 beds.
  • ACMH, Garden House, 165 East 2nd Street, New York, NY 10009. Phone (212) 253-6377 ext. 406 or 408. Fax (212) 253-8679. 10 beds.
  • ACMH, Independence House, 500 West 167th Street, New York, NY 10032. Phone (212) 274-8558. Fax (212) 253-8679.

Queens

  • WellLife, 507 Beach 54th Street, Arverne, NY 11692. Phone (718) 309-7486. Fax (347) 542-5847. 3 beds.
  • Transitional Services for New York (Miele’s Respite), 80-45 Winchester Blvd., Queens Village, NY 11427. Phone (718) 464-0375. Fax (718) 217-2366. 10 beds.

Staten Island

What Happens After You Submit

If a bed is available and the screening answers fit, you can stay up to 28 days in an open-door setting, meaning you can leave the building during your stay to keep appointments, go to work, or see family.1NYC Health. Crisis Services/Mental Health: Residential Crisis Support and Respite Centers Centers are staffed around the clock by peer counselors and licensed mental health professionals, and services include peer support, social support groups, recreational activities, self-advocacy education, and help linking to medical and psychiatric providers for care after you leave.4NYC 988. Crisis Respite

The reason the form asks whether you have a safe place to return to is practical. Staff begin discharge planning early in your stay, not on your last night, and if housing is unstable they can connect you with shelter resources before you leave.

Getting to the Center

If you have Medicaid and no way to get there, you can request non-emergency medical transportation through Medicaid Transportation Management at (844) 666-6270, available 24 hours a day.5NYC.gov. Medical Transportation for Medicaid Clients Have your Medicaid ID number, the center’s address, and your planned arrival date ready. Rides generally need to be booked at least two business days ahead, though same-day transport may be possible if you’re being released from a hospital or ED.

If you’re not on Medicaid, call 988. The counselor can help coordinate a respite referral and may be able to send a mobile crisis team to you. NYC Well at 1-888-NYC-WELL is another route to the same services.