Brighter Heights Maine

Client Info

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First Name*

Last Name*

Client Phone*

Client Email*

Date of Birth*

AMHI - Consent Decree Member*

Gender*

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Mental Health Diagnosis with F-Code (if known)

Insurance Information

MaineCare ID#

Insurance Company

Insurance Policy #

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Full Name

Parent / Guardian Address

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Phone

Programs/Services Requested*

Primary reason for referral / additional information

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Date of Submission*