• Home
  • About
  • Programs & Services
  • Locations
  • Referral Form
  • Employee Resources
  • Careers
  • Client Satisfaction Survey
  • Contact
  • Facebook
  • Notice of Privacy Practices
Skip to content
Brighter Heights Maine
  • Home
  • About
  • Programs & Services
  • Locations
  • Referral Form
  • Employee Resources
  • Careers
  • Client Satisfaction Survey
  • Contact
  • Facebook
  • Notice of Privacy Practices

Referral Form

* = required field
MM slash DD slash YYYY

Person seeking services

MM slash DD slash YYYY
Gender*(Required)
May we leave messages on your phone?
May we text you?
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.

Insurance Information

Do you have insurance in addition to or other than MaineCare?

What is the name of the other insurance?

Parent or Guardian, if appropriate

May we leave messages on your phone?
May we text you?

Emergency Contact

Services being sought

Preferred gender of provider:

Please read the descriptions for each program offered prior to making your selections.

Case Management/ BHH -MaineCare is required for this program. It is for children and adults with a qualifying mental health diagnosis. Children may have a diagnosis of intellectual/developmental disability in addition to a mental health diagnosis. It involves meeting regularly with a case manager who will assist clients in navigating and accessing services and supports to help meet their mental and physical health needs. The client and case manager provider determine the goals to work on. This may include: finding a medical provider or medical care, food, mental health services, school support, vocational services, and stable housing, among other things.

Case management/ Behavioral Health Home (BHH)

Adult Community Case Management (also called Targeted Case Management or Section 13) -MaineCare is required for this program. This program offers case management for those 18+ with a diagnosis of an intellectual disability, developmental disability, or autism spectrum disorder. Our case managers offer support and resources to help clients reach their goals identified in a Person Centered Plan. Those might include: building social supports, attending day programs, finding employment and housing, education and other supports.

Adult Community Case Management

Outpatient Therapy- is for those who can pay privately or have MaineCare. Children and adult clients will meet 1:1 in person or via telehealth with their therapist to talk about what is happening in their life, what is keeping them from their goals and working together to create a plan to address this. Check off which issues you are seeking therapy for. Please use the comments in the box at the bottom of this form to provide more information or add a concern that isn’t listed here. We use this information to make the best therapeutic match.

Outpatient Therapy Issues(Required)
Outpatient Therapy

Diagnostic Assessment - for those with MaineCare or the ability to pay privately. Children and adult clients meet for one session, in person or via telehealth, with a therapist to determine what their mental health diagnosis is. This is often needed to begin services with us and with other providers. A diagnostic assessment is not a full psychological evaluation and it is not used to diagnose autism spectrum disorders or ADD/ADHD.

Diagnostic Assessment

Medication Management - for children and adults with MaineCare or the ability to pay privately. This involves seeing a psychiatric nurse practitioner via telehealth to review your mental health and determine if medications may help. Our providers do not prescribe stimulants unless a client has a prior appropriate diagnosis

Medication Management (Psychiatric Medications)

Vineland Assessments - for ages 3 years and up and infrequently for adults, it measures adaptive behavior and supports the diagnosis of intellectual and developmental disabilities. It is also used as supportive documentation for services that include Section 28. While it is not a diagnostic tool on its own, it is frequently used to support qualification for services and identify extra needs.

Vineland Assessment

Substance Use Counseling - for those 18 and older with the ability to pay privately or with MaineCare, this is counseling for substance use

Substance Use Counseling

Medication Assisted Treatment for Opioid Dependency/ Opioid Health Home (OHH) - this is for those 18 years + with MaineCare. This program involves seeing a doctor for medication, a counselor, patient navigator (case manager) and peer, mainly via telehealth.

Medication Assisted Treatment for Opioid Dependence

Personal Support Services non-medical - for those 18 + with MaineCare and a Maximus assessment, this service provides in home care to meet the non-medical needs of those living with chronic health issues

Personal Support Services non-medical

Daily Living Skills (DLS) - for adults with MaineCare that have a severe and persistent mental health diagnosis. This requires a clinical letter from a licensed health professional attesting to this. This service provides 1-on-1 in-home care to assist clients to achieve the highest level of independence possible.

Daily Living Skills (DLS)

Services being Received

Are you/your client currently receiving any of these listed services?
Medication management*(Required)
Case management*(Required)
Outpatient therapy*(Required)
Substance use/ medication assisted treatment*(Required)
Have you/ your client received services from Brighter Heights Maine*(Required)

Demographics:

Interpreter needed:*(Required)

Who is making the referral

If self, click here

Notes:


  • Home
  • About
  • Programs & Services
  • Locations
  • Referral Form
  • Employee Resources
  • Careers
  • Client Satisfaction Survey
  • Contact
  • Facebook
  • Notice of Privacy Practices


Take Our Satisfaction Survey
©2025. All Rights Reserved.
  • Home
  • About
  • Programs & Services
  • Locations
  • Referral Form
  • Employee Resources
  • Careers
  • Client Satisfaction Survey
  • Contact
  • Facebook