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Home
About
Programs & Services
Locations
Referrals
Employee Resources
Careers
Client Satisfaction Survey
Contact
Facebook
Referral Form
Complete this encrypted and HIPPA compliant form online or print and fax to 207 338-8962
Who is making the referral
Name of organization if any
Upload most recent Diagnosis
Upload most recent Psychosocial assessment
Upload most recent Treatment plan
Person seeking services
Gender
Male
Female
Trans
Other
May we leave messages on your phone?
yes
no
May we text you?
yes
no
AMHI Consent member Y N Unsure (if yes, diagnosis is required)
Yes
No
Unsure
Parent or Guardian, if appropriate
May we leave messages on your phone?
yes
no
May we text you?
yes
no
Emergency Contact
Insurance Information
Do you have insurance in addition or other than MaineCare
Yes
No
What is the name of the other insurance?
Services being sought
Reason For Referral:
Goals of treatment:
Preferred type of therapy, if any (i.e. EMDR, DBT, CBT etc.)
Preferred gender of provider:
Male
Female
Trans
Other
Please check off the services requested:
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
Yes
No
Case management
Yes
No
Outpatient therapy
Yes
No
Substance use/ medication assisted treatment
Yes
No
Have you/ your client received services from Brighter Heights Maine
Yes
No
Demographics:
Primary language
Interpreter needed:
Yes
No
Level of education received
Notes
What else would you like us to know?
