BEHAVIORAL HEALTH SERVICES

REFERRAL FORM

Maine Immigrant & Refugee Services

256 Bartlett Street
Lewiston, ME 04240
Phone: 207-782-0260
Fax: 207-782-0261

*** These programs are available through MaineCare. ***

Please complete all fields then sign and submit this form below.


CLIENT INFORMATION



Legal Guardian(s)


Reason(s) for Referral: (Check all that apply and provide more information for each checked box)