C-YES Online Referral | Survey Builder

Welcome to the Children Waiver online referral.

Thank you for taking the time to fill out this referral. Your information will help the New York State Department of Health, Children and Youth Evaluation Services (C-YES) understand the child’s/youth’s needs and make sure they will get the right services.

**If the child/youth you are filling this out about, already has Medicaid, please see the website resources to contact the Health Home program as they can assist you. This Online Referral is not for children/youth who are already in Medicaid. To find a Health Home in your county please refer to the following link: Find A Health Home By County

For information or to ask questions, call

Toll-Free: 1-833-861-4467 or Local: 518-408-5358

Children’s Waiver Home and Community-Based Services (HCBS) help children and youth with complex health, and/or behavioral needs by providing supportive services in their home and community—not in a hospital, nursing home, or other placement. These Medicaid services are designed to help children stay safe, grow, and succeed at home, in school, and in their community. HCBS can include supports such as teaching daily living skills, providing caregivers with a planned break from caregiver responsibilities, offering caregiver training and support, and more.

The goal of HCBS is to give children the support they need where they live and learn, while helping families feel confident and supported. These services are only for children/youth who might go to a hospital, nursing home, or other placement OR who are in a hospital, nursing home, or other placement to help them return to their home and community.

Children and Youth Evaluation Services (C-YES) work with families and providers to understand children’s needs and help them get connected to Children’s HCBS or other services. If found to meet HCBS, Children and Youth Evaluation Services (C-YES) can assist children/youth with the Medicaid application.

To refer a child/youth to C-YES and see if they will meet enrollment in the Children's Waiver, complete the C-YES referral form below, if the child/youth does NOT have Medicaid.

This referral will ask you questions about the child’s health, supports, and Medicaid status.

Please answer each question the best you can. Once submitted, your referral will be sent directly to C-YES staff for follow-up. If you give us an email address, and you will receive a message that we received your referral.

If you have questions or need assistance, please contact us:

Toll-Free: 1-833-861-4467
Local: 518-408-5358
Email: CYESConnect@health.ny.gov

1: Medicaid Coverage

Does the child/youth you are referring currently have active Medicaid?

Yes

No

Unsure

*If yes, please do not complete this referral and use the following link to find a Health Home.

Medicaid (CIN) Number

If "Yes" enter Medicaid (CIN) Number

2: Child/Youth Condition(s)

The child/youth currently have the following (check all that apply):

Medically Fragile/Complex Medical Condition (long-term, life threatening, or specialized medical needs)

*If the child/youth has a Developmental Disability, the child youth must be deemed eligible for OPWDD services, and have a complex medical condition that places them at risk of going to a hospital, nursing home, our other out of home placement.

Mental health (Behavioral concerns, mental health diagnosis/condition, Serious Emotional Disturbance (SED), and/or in mental health treatment)

*To be eligible for HCBS, the child/youth’s condition(s) must be severe enough, in which they are at imminent risk of going to a hospital, nursing home, or other placement OR due to their condition(s) they are currently in a hospital, nursing home, or other placement and planning to return to the community.

3: Information of Child/Youth Being Referred

First Name

Last Name

Date of Birth

Child/Youth Age

County of Residence

Child's/youth's sex assigned at birth

Male

Female

4. Preferred Language

What is the family's preferred language?

Do you need language interpreter services?

5: Your Information/Person Completing Referral

Referent First Name

Referent Last Name

Email Address

Telephone Number

Title/Relationship to Child/Youth

6: Parent/Guardian Information

Are you the parent or legal guardian of the child/youth?

Yes

No

First Parent/Guardian Details

Primary Parent/Guardian First Name

Primary Parent/Guardian Last Name

First Parent/Guardian Type

First Parent/Guardian Email

First Parent/Guardian Phone Number

Second Parent/Guardian Details

Second Parent/Guardian First Name

Second Parent/Guardian Last Name

Second Parent/Guardian Type

Second Parent/Guardian Email

Second Parent/Guardian Phone Number

7: Referred

Did someone refer you here or tell you the Children’s Waiver / Home and Community Based Services (HCBS) would be helpful. If Yes, provide who referred you and why?

Yes

No

Who referred you?

Why did they refer you?

8: Reason for Referral

Please provide a brief summary of why you are completing this referral

What are the needs of the child/youth you are referring?

9: Other

10: Referral Permission

If you are not the parent, caregiver, or legal guardian, have you received permission from the parent, caregiver, or legal guardian to submit this referral on the child's behalf?

Yes

No

Not applicable*

*I am the parent/legal guardian

11. Contact Time

What is the best time of day to contact you?