Referral Form for Admissions

Submit the referral for admission on this page.

Self-Referrals: Please call our Admissions Office at 845-335-1020 for a screening.
Our hours are Monday-Friday, from 8:00am – 4:30pm (Eastern).

Print Option – Referral Form

Complete the form on paper and then fax it to Admissions (845-424-4537).

Download Printable Referral Form

Online Option – Referral Form

Complete the form online below.

"*" indicates required fields

Agency Information

Agency Name*

Contact Name*

First Last

Phone Number*

Email*

FAX Number

Client Information

Client Name*

First Last

Client Social Security #

Client DOB*

Insurance Plan

Medicaid CIN #

Insurance ID # (optional)

Client Discharge Date

Date of last TB Test

Date of last History & Physical Exam (H&P)

Note: If H&P was completed at your facility, it must be signed by an MD or NP and provided with this form.

Registered Sex Offender?

Yes

If Yes, which Level?

Level 1

Level 2

Level 3

Any Seizure History?

Yes

Client’s Preferred Language:

Psychiatric History / Diagnoses

Provide psychiatric evaluation if available.

Medical History

Provide documentation for any recent hospitalizations (i.e., surgeries, medical conditions, etc.)

Current Medications

Submit a LIST of all your client’s current medications.

IMPORTANT: If client is prescribed medications, you must be E-scribed to our PHARMACY. **Clients should be made aware that they may be responsible for medication Co-Pays. Prescription Center 296 Route 59 – PO Box 64 Tallman, New York 10982 Phone: (845) 368-9700 / FAX: (845) 368-4056

Pending Appointments

List any Medical, Legal or Other appointments.

Upload a Copy of Client's ID (Front and Back)

Drop files here or

Max. file size: 50 MB.

Client File Upload

Drop files here or

Max. file size: 50 MB.

Referral Agencies: Please INCLUDE ALL the following info with this referral: ❑ Insurance information ❑ List of Medications & Diagnoses ❑ History & Physical Exam ❑ TB Test Results: Any ONE of the following: ❑ PPD -or- ❑ Chest X-Ray -or- ❑ QuantiFERON Gold test TB Test Results: If “+” PPD history, a negative chest x-ray within the past 12-months or a QuantiFERON Gold blood test must be obtained. ❑ Bio-Psychosocial ❑ Psych Eval if on psychotropic meds

Resident Frequently Asked Qustions*

**By signing below, I acknowledge that I have read the above document and understand its contents.

Can I have my cellphone while in the program?
No cellphones / no Smartwatches / no laptops / and no Tablets. Your cellphone will be securely stored and may be used at the discretion and supervision of your counselor. Residents are permitted three phone calls per week using a phone card (obtained from us for $5.00). One phone card will provide ten phone calls; any additional calls need counselor approval.

Am I allowed to have visits?
We have a family program. Thirty days after admission, your counselor will work with you to set a date for a family visit supervised by your counselor.

How long until I can go out on my own?
When you are not in meeting sessions, you have the freedom to go outdoors on our property during ‘free’ time. You are not permitted to leave the grounds unless you have an approved appointment for which we will provide transportation.

How many people sleep in a room?
We have 13 dormitories. Depending which dorm you are in, the number of beds in a dorm range from 7 to 18 men in a room.

Am I allowed to get a job?
You are not permitted to obtain an outside job. While here you are assigned a vocational activity on premises as part of your treatment plan.

How many meetings per day?
Three meetings: a small group, a lecture, and an evening AA/NA meeting.

Is this a smoking facility?
Can I bring my own cigarettes/vape? This is currently a smoking facility with a limited tobacco program (i.e., designated smoking times and cigarette tapering). You may bring your own cigarettes (packs must be sealed and handed to security upon arrival). NO Vapes/Vaping allowed. If brought with you, ALL vaping devices will be discarded.

How long is this program?
The length of your stay depends on your treatment plan, goals, and insurance coverage. Typically, our residential treatment program is about 90 days or longer. Your length of stay ultimately depends on when you meet your individual goals and what your insurance will cover.

Is this facility co-ed?
No, we have only MALE residents.

Is transportation provided to outside AA meetings?
No, we have an onsite AA meeting each evening.

Do you offer weekend passes?
No.

Does this facility have a gym?
We have a workout room with exercise machines and weights that can be utilized during your free time.

Do you help with housing?
We offer referrals for your aftercare plan and aid in finding sober housing. We do not aid in obtaining rentals, applying for Section 8 or that type of housing.

Am I allowed to use a computer/laptop?
With permission from your counselor for specific reasons.

Can I attend school? Do you offer any classes or help finding classes or college?
Not at this current time, but a program called Access VR is part of your aftercare and they do aid in the education process.

Client Signature*

Notice Regarding Department of Social Services/Human Resources Administration Benefits and NYS OASAS Part 820 Residential Treatment Program*

I acknowledge that I have read the above information and understand it, or it has been explained to me. Once I am admitted to St. Christopher’s Inn, I understand that I will be assisted by the Billing and Clients Services Office to help with the process.

1. There are three levels of benefits typically provided by DSS/HRA:
a. Congregate Care Level II — Room and Board
b. SNAP — Supplemental Nutrition Assistance Program
c. PNA — Personal Needs Assistance

2. As a resident of a NYS OASAS approved Part 820 Residential Treatment Program you will be
required, if eligible, to apply for all DSS/HRA benefits as described above.

3. If you have an active DSS/HRA benefits case upon admission to St. Christopher’s Inn, DSS/HRA will be notified of your admission, and your budget may be adjusted to include Room & Board and PNA. Those with active benefits that include family members, your portion will be removed from the total amount provided for the family while you are here at St. Christopher’s and will be restored fully when you complete treatment or if you decide to leave.

4. SNAP benefits will be applied for and provided through Putnam County Department of Social Services.

5. Room & Board and SNAP benefits will be made payable to St. Christopher’s Inn to support your stay here.

6. If you are eligible for PNA, those funds will be provided to you.

7. If you are a recipient of Supplemental Security Income (SSI) and/or Social Security Disability
income (SSDI), you will be required to pay St. Christopher’s Inn an amount for Room & Board
according to the amounts set annually by the Social Security Administration for Congregate Care Level II settings.

8. All mail from DSS/HRA and SSA may be opened by Billing & Client Benefit Services staff so that documentation requests and other matters requiring timely action can be acted upon.

Client Signature*

The nurses are the best part of my day.

The admission process was as fast and painless as it could be.

The medical staff is excellent, they treated me with love and care.

Overall the program and facility at St. Christopher’s Inn is the best, bar none.

Family program is PERFECT please don’t change a thing.

I took part in the GED program and was quite satisfied. I haven’t taken the test yet, but I have very high hopes of passing.

Gained immense knowledge from lectures and treatment plan.

It is very spiritual and I needed the experience.

The care and concern by my counselor and supporting staff shows the love that I didn’t know existed.

Staff is unbelievable, saved my life.

The goals I have reached and the new ones I’ve developed while being here are something of a life changer for me in my future.

I was pleasantly surprised by the existence of the Coffee House. Music is a central and meditative part of my life. The ability to perform for my new brothers here and the staff was unexpected and made this an incredible journey.

I would have nothing if it wasn’t for SCI.

Great people, caring and responsive.

I would like to tell you how thankful I am to you for having this family program available. I want to say thank you for giving me exactly what I needed.

The experience of being here and becoming a member of the Brothers Christopher fraternity has changed my life. Being in the Friars house was a blessing. Their generosity gave me knowledge I will carry with me for the rest of my life.

Thank you for the privilege I was given to stay here in your house. God bless you all. I will always keep a piece of St. Christopher’s Inn in my heart.

I thank you from the bottom of my heart for all the hot meals, warm bed and unconditional love you so easily gave to me. I know if it were not for you, I would truly still be a lost soul.

The road to recovery is called Franciscan Way, and the door to happiness lies within the walls of St. Christopher’s Inn.

I never thought someone could care for a drug addict like me. You have shown me that I am worth something. May God bless you a million times.

Thank you for welcoming me in to your home, and granting me a scholarship for treatment. There’s not enough “thank-yous” I could say, so I’m going to show you by staying clean and living a peaceful sober life.

I want to thank you for everything—from my stay here to working in the Thrift Shop. I am so grateful for St. Christopher’s Inn and every staff member that represents this fantastic organization.

I was amazed by the unbelievable generosity of everyone at our Christmas party. A nice scarf and a collared shirt—I have been through hundreds in my life but I have never cared for any of them as I do for these. Thank you for giving me the best Christmas in many, many years.

I love this place. They have given me a place to sleep, food in my stomach, clothes on my back, and a chance at a first-class life. Recovery is here . . . all you have to do is want it!

Today, I am a sober man. I live an honest and simple life. I’m a reliable, employable productive member of society. I have dignity and self-worth and even self-love. All of these things are a direct result of the care and guidance given to me by the Friars and the staff at St. Christopher’s Inn. Some people call it a homeless shelter. I call it home.