Confidential Service Request

If you are concerned about yourself or about somebody else, please call the crisis hotline. This will connect you to your closest crisis center Crisis hotline:

1-888-568-1112 or National Suicide Prevention Lifeline:
1-800-273-TALK (8255)

Are you making a referral for someone else?

Yes

Name of individual completing this form

First

Last

Referrer's Phone

Referrer's Email

Relationship to Applicant

Agency Name (if referring a client)

Client Information

Name of individual (client) seeking service

First

Last

Date of birth of individual seeking service

Does the client have a guardian?

Yes

Name of Guardian

Address

Street

City/Town

State

Zip Code

Phone

Client Email Address

For Case Management Referrals: If an email address is provided, the Referral Care team will email a list of alternative agencies in the event that the referral cannot be placed immediately and check-in every 30 days regarding status until placement is found. A list of alternative organizations for case management can be found by accessing 211Maine.org or dialing 211.

Is the individual (client) seeking service a class member?

Yes

What gender would the individual (client) prefer their provider to be?

No Preference

Male

Female

Other

Other Gender Preference

Has the individual (client) ever served in the U.S. Armed forces?

Yes

Does the client have active legal issues?

Yes

Please list any relevant charges and pending court dates.

How did you hear about us?

Please tell us a little bit about how you heard about us.

Services Requested

Preference for Services (mark all that apply):

In Person

Telehealth (I/Client has video/audio capability for web based meetings)

Are Interpreter Services needed?

Yes

What language does the client speak?

Other Language

Please select the services you are requesting

Psychiatric Assessment & Treatment (Medication Management)

Intensive Outpatient Program (IOP)

Case Management (including Behavioral Health Home)

Counseling/Therapy

Substance Abuse Counseling

Services for the Armed Forces

Maine National Guard & Air Guard Services

Allergies to Medications

Suicide Attempts

Inpatient Hospitalizations

Current or Previous Treatments

Current or Previous Hospitalizations

Current Symptoms

The reason for seeking services?

Does the client have a history of violence/aggression?

Yes

Please Explain

Does the client have a history of substance abuse?

Yes

Alcohol or substances.

Please Explain

Current Psychiatric Medications and Dosage

Is your insurance Medicare Advantage?

Yes

Additional Comments

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Individuals

Health Professionals

Schools

About Us

Client Information

Services Requested

Physical Address

Phone

Mailing Address

Fax

Email