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Make a Referral

Complete the form below and click Submit to send the referral online.

Referral Source Information

Referring Source/Agency Name *

Parent or client

Contact Name

First

Last

Contact Email *

Contact Phone Number *

Referral Details

Please select the programs/services in which you are referring the client for:

Outpatient Counseling (All ages, available in Lewiston & surrounding areas only)
Targeted Case Management (ages 0-20 only, available in Brunswick & Lewiston areas)
Home and Community Treatment (ages 0-20, available in Lewiston & surrounding areas only)
Community Support Services (ages 18+, available in Lewiston & surrounding areas only)

Does the client have a mental health diagnosis? *

Specify if yes:

Reason for Referral

Does the client require an interpreter? *

Specify if yes:

Client Information

Client Name *

First

Last

Client Date of Birth *

Client Gender

Female
Male
Other

Client Home Phone Number

Client Cell Phone Number

MaineCare Member ID *

Client Address

Address Line 1

Address Line 2

City

State

Zip Code

Client's Parent or Legal Guardian Information (optional if client is aged 18+)

Parent or Legal Guardian Name

First

Last

Relationship to Client

Parent or Legal Guardian Address (if different from the client's)

Address Line 1

Address Line 2

City

State

Zip Code

Parent or Legal Guardian Home Phone Number

Parent or Legal Guardian Cell Phone Number

Additional Comments

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