Font Size: A+ | Reset | A-

HHUNY Online Community Referral

*Fields are required

1. Contact Information for Person Completing Referral

If the referral is for a youth between the ages of 18-21, please complete the following and check all that apply.

If child is under 18 years of age STOP, do not continue this referral.

Please DO NOT COMPLETE THIS FORM. Contact your local LDSS for further direction.

2. Identifying Information of Person Needing Services

CIN has 8 characters total: 2 letters, 5 numbers, 1 letter. e.g. - ab12345c

If CIN unavailable, provide SS # in narrative below (Section 5).

3. Eligibility Category Information - Check All that Apply

Must meet either:

  • A only
  • B only
  • A and any number of C's
  • B and any number of C's 
  • Two or more C's to be eligible

Make sure to specify the diagnosis.
E.g. - Serious mental illness - 296.8 Bipolar Disorder NOS
E.g. - Other chronic conditions - COPD

4. Risk Factors - Check All that Apply

Give some detailed information concerning member's risk factors

E.g. - Member is at risk for hospitalization due to non-adherence with medication

5. Narrative

Provide any additional information that may be helpful in assignment to a care management agency

Disclaimer and Consent Form

Please, before checking box, read our Consent Form

Please click on attachment A to view the list of agencies and organizations that your information may be disclosed to, only when necessary for your referral to be processed.
Attachment A for Central Region
Attachment A for Finger Lakes Region
Attachment A for Southern Tier Region
Attachment A for Western Region