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focused

outreach.

coordinated

care.

housing

assistance.

Offering Comprehensive Care to People Experiencing Homelessness

The Safe Options Support (SOS) Program addresses the needs of individuals experiencing homelessness on the street or places not meant for human habitation, and individuals placed in temporary shelter settings by offering direct linkages to services that address their immediate needs and providing support during transition from street homelessness to stable housing.

The SOS team utilizes a person-centered and trauma-informed approach to meet people where they are at in the community. A Critical Time Intervention (CTI) – based case management model, which is a time-limited, evidence-based service that helps vulnerable individuals during periods of transition, is used to address needs. The SOS team consists of licensed behavioral health clinicians, case managers, and peer specialists from Endeavor Health Services.

To make a referral, please either a) fill out the form below or b) download the Word Document and send via email.

Chenango/Broome/Otsego Safe Options Support Referral Form

Referrer Info...

Items marked with * are required

Referring Agency/Program

Referring Worker’s Name

Contact Phone

Referrer Email

Alternative Contact

Alternative Contact Phone

Authorization

I authorize the above referral source to disclose the completed Safe Options Support Referral Application and all related supporting documents (Application), including confidential medical and mental health information, to the Chenango/Broome/Otsego Safe Options Support team (CBO/SOS) , for the purposes of CBO/SOS conducting a clinical assessment and coordinating health care and related services, including community support services and housing placement assistance, for a period of three hundred and sixty five days (365) . As part of this referral process, I understand that CBO/SOS will separately obtain my authorization and consent as part of the initial assessment and intake process before providing or coordinating the provision of any additional health care services. I understand that I may revoke my consent to disclose the completed Application at any time. I am aware that my revocation will not be effective if CBO/SOS has already received the Application because of my earlier authorization and consent; however, I can instruct CBO/SOS to take no further action following its receipt of the Application.

Client Info...

Name (alias or street name)

Gender

Address (known location or description of where person is residing)

Client Phone #

Alternative way to contact (email, alternative #, etc.)

Primary Language

Presenting Problem(s)

What barriers is the applicant experiencing that the SOS team can assist with (housing, substance use, behavioral health, chronic health conditions, mobility, etc.)

For Health Care Providers Only...

Outpatient Behavioral Health and Medical Clinics / Health Home / Outreach Team / Shelter: Provider Name

Address

Contact Info-Telephone/Email

Any known Behavioral Health Diagnosis

Any known Substance Use Diagnoses

Any known Medical Disorders

Supporting Files...

If you would like to include any relevant supporting documentation to better help us understand background on client (psych evaluation, medical records, etc.), please attach it with referral. Please note this is NOT a requirement of the referral.

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