Referral

Referral
Service Access Request Date*

MonthDayYear
Date
Adult:

Behavioral Health Home (Care Coordination/Case Management)Mental Health Outpatient AssessmentMental Health Outpatient Therapy
Children:

Behavioral Health Home (Care Coordination/Case Management)Mental Health Outpatient AssessmentMental Health Outpatient Therapy
Reason for Referral:
Reason for Referral:
Referring Individual*
Relationship to patient*
Agency Name (If Applicable)
Referrer Phone Number*

Area CodePhone Number
Email Address (Optional)
example@example.com
Interpreter services needed?
If yes, language needed:
Name of person completing this form:*
Receiving Services from other agencies?*
If yes, where?
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender
Patient Phone Number*

Area CodePhone Number
Marital Status
Current Vocational/Employment Status:*

Clubhouse Transitional EmploymentCompetitively employed full-time (32 or more hours per week)Competitively employed part-time (Less than 32 hours per week)Not employed – looking for workNot employed – not Looking for workSelf-employedStay-at-home parent of a child under the age of 18StudentVolunteer on a regular basis (in the last 30 days)Working with supports full-time (32 or more hours per week)Working with supports part-time (Less than 32 hours per week)
Employer or Type of Work
ABHS works very hard to schedule and complete an intake for our programs as soon as this referral is received. In order for this to occur it is helpful if the individual has a current diagnosis signed and dated by their medical/behavioral health provider and uploaded with this referral.
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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
Current Residence:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Parent/Guardian Information (required if member is under age 18)
Status:

Own Guardian (Age 18+)Parents Married & Living TogetherShared Custody (both must sign paperwork)Sole Custody (Copy of Custody Agreement or PFA)Other Guardianship (copy of guardianship required)
Parent/Guardian Name

First NameLast Name
Residency?
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name

First NameLast Name
Residency?
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: