New York Presbyterian

Forge Health and New York Presbyterian are partnering to provide evidence based mental health and substance use care for individuals, both in-person and virtually.
Please fill out the form below.

Upon submission, both you and the referred individual will promptly receive an email confirmation.

Forge Health will work directly with the client to coordinate a level of care assessment

Please provide your information:

Your first name:*

Your last name:*

Your phone number:*

Your email address:*

NewYork – Presbyterian Location*

Department*

Please provide us with the patient’s information:

Patient's first name:*

Patient's last name*

Patient's date of birth:*

Patient's Address*

City*

State*

Zip Code*

Patient's email*

Patient's phone number:*

Patient Insurance information:

Insurance Type*

Forge Health partners with most major insurance companies. *Medicaid and Medicare are accepted at select locations.

Insurance Provider*

If your insurance provider is not on this list, please select “Insurance Not Listed”

Patient's member ID:*

Your member ID can be found on your insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

Patient's Insurance Provider*

Please provide the name of your insurance company and upload images of both the front and back of your insurance cards.

Service Inquiry:

Is the patient interested in in-person or telehealth services?*

In Person

Telehealth

What is the patient's primary need?*

Mental Health

Substance Abuse / Addiction / Alcohol

Other

Which service(s) are you recommending for this patient?*

Therapy Services

Psychiatric / Medical Services

Tell us a little more about the patient and their current needs:*

Location Preference:

Patient's Preferred Location for Services:*

Location Preference:

Patient's Preferred Location for Services:*

Supporting Clinical Documents (optional)

File

Max. file size: 256 MB.

Please include relevant medication information – specifically a current medication list (including doses) and medication allergies. Additional relevant information could include: most recent oncology note, medical/oncologic history, oncologist contact information, and behavioral health screening results (e.g., PHQ9, GAD7).”

Consent

I give or have obtained any necessary consent/authorization prior to disclosing the health information above. The patient is aware of this referral and is expecting Forge Health to contact them directly via phone, voicemail, SMS/text, and email as appropriate.*

Yes

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