Referral

Referral
Date of Referral *

Month Day Year
Date
Services

Mental Health Outpatient Therapy COMP ASSESSMENT
Adult:

Adult Case Management Behavioral Health Home Organization Daily Living Skills SKILLS
Children:

Targeted Children’s Case Management Behavioral Health Home Organization
Referring Individual *
Relationship to patient *
Agency Name (If Applicable)
Referrer Phone Number *

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

First Name Last Name
Date of Birth *

Month Day Year
Gender
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

City State

Zip Code
Phone Number

Area Code Phone Number
Primary Diagnosis, LOCUS, GAF
AXIS 1 (ICD-10)
LOCUS:
Completed By:
Copy of Diagnosis Provided?
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 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 State

Zip Code
Should be Empty: