Home
About
Programs & Services
Locations
Referral Form
Employee Resources
Careers
Client Satisfaction Survey
Contact
Facebook
Notice of Privacy Practices
Skip to content
Home
About
Programs & Services
Locations
Referral Form
Employee Resources
Careers
Client Satisfaction Survey
Contact
Facebook
Notice of Privacy Practices
Referral Form
* = required field
Today's Date
MM slash DD slash YYYY
Person seeking services
First Name
(Required)
Last Name
(Required)
Date of Birth*
(Required)
MM slash DD slash YYYY
Phone*
(Required)
Email*
(Required)
Gender*
(Required)
Male
Female
Nonbinary/Other
Street Address*
(Required)
Town*
(Required)
Zip
(Required)
May we leave messages on your phone?
Yes
No
May we text you?
Yes
No
Upload most recent Diagnosis
Max. file size: 50 MB.
Upload Release of Information Authorization signed by the person being referred
Max. file size: 50 MB.
Upload most recent Psychosocial assessment
Max. file size: 50 MB.
Upload most recent Treatment plan
Max. file size: 50 MB.
Payment & Insurance
How will you pay for services?*
(Required)
MaineCare
Other insurance
Self-pay (not using insurance)
MainCare
MaineCare#
Other insurance
Insurance Name
Insurance ID#
Policy holder name
Relationship to policy holder
Upload insurance card (front & back)
Drop files here or
Select files
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 50 MB, Max. files: 2.
Contact Information (if parent/guardian)
Name
Phone
Email
May we leave voicemail?
Yes
No
May we text you?
Yes
No
Emergency Contact
Name*
(Required)
Phone*
(Required)
Relationship*
(Required)
Services Requested
What services are you interested in? (check all that apply)
(Required)
Therapy (1:1 counseling)
Diagnostic Assessment (mental health evaluation)
Medication Management (psychiatric medications)
Case Management / Behavioral Health Home (BHH)*
Adult Community Case Management (18+)*
Substance Use Counseling (18+)
Medication Assisted Treatment (OHH) (18+)*
Vineland Assessment
Personal Support Services (home care – MaineCare)
Personal Support Services (self-pay)
*Requires MaineCare
Your Needs
Reason for referral:*
(Required)
Goals for treatment:*
(Required)
Preferences
Preferred gender of provider:
Male
Female
No preference
Learn more about services
Therapy
Ongoing 1:1 counseling (in person or telehealth)
Diagnostic Assessment
One-time visit to determine diagnosis
Medication Management
psychiatric medications for those 3+
Case Management (BHH)
Help accessing services (MaineCare required)
Adult Community Case Management
Help accessing services for adults with IDD (MaineCare required)
Substance Use Counseling
counseling for adults that use substances other than opioids
Medication Assisted Treatment (OHH)
treatment program using medication and counseling for those using opioids (MaineCare required)
Vineland Assessment
used to support a diagnosis of IDD
Personal Support Services
this is nonmedical homecare for adults (MaineCare or self-pay required)
Services being Received
Are you/your client currently receiving any of these listed services?
Medication management*
(Required)
Yes
No
Case management*
(Required)
Yes
No
Outpatient therapy*
(Required)
Yes
No
Substance use/ medication assisted treatment*
(Required)
Yes
No
Have you/ your client received services from Brighter Heights Maine*
(Required)
Yes
No
Demographics:
Primary language*
(Required)
Interpreter needed:*
(Required)
Yes
No
Who is making the referral
If self, click here
Name*
(Required)
Phone*
(Required)
Email*
(Required)
Name of organization if any
Notes:
What else would you like us to know?
