referral

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.

Date

Referring Source / Agency

Is this an urgent referral?

Yes No

If Yes, explain

Does the client have a current mental health diagnosis?

Yes No

If Yes, what is the dianosis?

Name of diagnosing physician / clinician

Diagnosis or assessment date

Is the client consent decree?

Yes No

CLIENT INFORMATION

Last Name

First Name

Middle (Initial)

Gender

Male Female

Date of Birth

Maine Care #

Other Insurance

Policy #

Policy Holder

Group #

Home Phone

Cell Phone

S.S.N.

Physical Address

City

State

Zip Code

Referral Source

Phone

Fax

Legal Guardian(s)

Guardian Name

Home Phone

Cell Phone

Address

Guardian Name

Home Phone

Cell Phone

Address

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

Mental health concerns

Social concerns/family support

Financial/housing/community resource needs

Transportation needs

Chronic/complex medical condition

Chronic pain concerns

Behavioral issues

Educational Issues

Cultural adjustment issues

Other

Primary Language

Interpreter needed?

Yes No

Additional Information

Person Referring Printed Signature

Date

Check this box to acknowledge that your printed signature above represents your signature for this referral form.

Person Referring Signature (use mouse to sign or stylus if you have touchscreen)

[Click here to clear signature and retry]