Atlas Referral Program - Single Referral Entry

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You are entering the Atlas referral program. Please answer the following security question to move on to the referral submission form.

What is five + five?

Please enter your response as a number

Referral Information ( denotes required field)*

Referral First Name (Youth/Young Adult/Adult)

Referral Last Name (Youth/Young Adult/Adult)

Referral Date of Birth or Referral Age (if Date of Birth is not available)

Referral Date of Birth

Must enter if Referral DOB is known.

Referral Age

Must enter if Referral Age is known.

Referral Location

Referral Zipcode

Referral Phone Number

Referral Alternate Phone Number

Preferred Call Time from Atlas Provider

Referral Email

If No Email or Phone, Social Media Handle

Referral Gender

Referral Race

Referral Ethnicity

Referral Language

Family Contact Information

Family Contact First Name

Family Contact Last Name

Relationship to Family Contact

Family Contact Phone Number

Family Contact Alternate Phone Number

Family Contact Email Address

Number of People in Household

What was the approximate date that the person first agreed to be referred to Atlas?

I, as an employee or agent of the Referring Organization, attest that this Referral to the Atlas program, a joint initiative between the City of New York and the United Way of New York City, is being made with the informed consent of the Referred Individual. Further I, as an employee or agent of the Referring Organization, understand that all Personally Identifying Information and Person Health Information collected for and related to Atlas shall be used, restricted, safeguarded, and disposed of in accordance with the Atlas Subcontract between the City of New York and the United Way of New York City, all relevant Data Sharing Agreements, and all applicable federal, state, and local laws, statutes, regulations, and policies.

I agree

Additional Referral Information if available or applicable (contd.)

NYSID Identifier

Arrest Number

Docket Number

Arraignment Date

Submitter Information

Submitter First Name

Submitter Last Name

Submitter Email Address

Submitter Phone Number

Referral Agency

Comments

Single Entry TRUE

TRUE

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