Referral
Service Access Request Date
*
-
Month
-
Day
Year
Date
Services
Mental Health Outpatient Therapy
COMP ASSESSMENT
Adult:
Adult Case Management
Behavioral Health Home Organization
Daily Living Skills
SKILLS
Children:
Behavioral Health Home Organization
Reason for Referral:
Referring Individual
*
Relationship to patient
*
Agency Name (If Applicable)
Referrer Phone Number
*
-
Area Code
Phone Number
Email Address (Optional)
example@example.com
Interpreter services needed?
Select
Yes
No
If yes, language needed:
Name of person completing this form:
*
Receiving Services from other agencies?
*
Select
Yes
No
If yes, where?
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
Select
Male
Female
N/A
Patient Phone Number
*
-
Area Code
Phone Number
Ins./Medicare #
Medicare only accepted when coupled with Mainecare, unless for the OHH program
Ins./Mainecare #
If you do not have any coverage, you may be eligible for grant funding
Self Pay
Select
Yes
No
Current Residence:
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
-
Area Code
Phone Number
Parent/Guardian Information (required if member is under age 18)
Status:
Own Guardian (Age 18+)
Parents Married & Living Together
Shared Custody (both must sign paperwork)
Sole Custody (Copy of Custody Agreement or PFA)
Other Guardianship (copy of guardianship required)
Parent/Guardian Name
First Name
Last Name
Residency?
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian Name
First Name
Last Name
Residency?
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Submit
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