Appointment Requests

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

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

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

Telehealth Counseling

Substance Abuse Counseling

Services for the Armed Forces

Maine National Guard & Air Guard Services

DEEP Assessment

Allergies to Medications

Suicide Attempts

Inpatient Hospitalizations

Current or Previous Treatments

Current or Previous Hospitalizations

Case Management Type

Adult CM

Child CM

Adult BHH

Child BHH

Unsure

Diagnosis

Date of current diagnosis

Current provider treating this diagnosis. (Please include the provider's credentials. ie: MS, LSCW, MHNP, LCPC, MD)

Provider Phone Number

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

Insurance ID#

Additional Comments

Statewide Crisis Line: 1-888-568-1112

Physical Address

306 Rodman Road
Auburn, ME 04210

Phone

207-333-3278
1-877-888-4304

Mailing Address

PO Box 1150
Auburn, ME 04211

Fax

207-333-3037

Email

info@healthaffiliatesmaine.com

Individuals

Health Professionals

Schools

About Us

Appointment Requests

Physical Address

Phone

Mailing Address

Fax

Email