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Home
About
Programs & Services
Locations
Referral Form
Employee Resources
Careers
Client Satisfaction Survey
Contact
Facebook
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
Trans
Other
Street Address*
(Required)
Town*
(Required)
Zip
(Required)
May we leave messages on your phone?
Yes
No
May we text you?
Yes
No
AMHI Consent member (if yes, diagnosis is required)
Yes
No
Unsure
Upload most recent Diagnosis
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.
Insurance Information
MaineCare#
Do you have insurance in addition to or other than MaineCare?
Yes
No
What is the name of the other insurance?
Name
Insurance#
Name of policy holder
Relationship to policy holder
Parent or Guardian, if appropriate
Name
Phone
Email
May we leave messages on your phone?
Yes
No
May we text you?
Yes
No
Emergency Contact
Name*
(Required)
Phone*
(Required)
Relationship*
(Required)
Services being sought
Reason For Referral:*
(Required)
Goals of treatment:*
(Required)
Preferred type of therapy, if known (i.e. EMDR, DBT, CBT etc.)
Preferred gender of provider:
Male
Female
Trans
Other
Please check off the services requested:*
(Required)
Case management/ Behavioral Health Home (BHH)
Outpatient Therapy
Diagnostic Assessment
Medication Management (Psychiatric Medications)
Vineland Assessment
Substance Use Counseling
Medication Assisted Treatment for Opioid Dependency/ Opioid Health Home (OHH) for 18 years +
Personal Support Services non-medical
Daily Living Skills (DLS)
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
Level of education received*
(Required)
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?
