Referral Form

In order to process your referral in a timely manner, please complete as much as possible.

Consumer Identifying Information

Name *

First Name Last Name

Date of Birth *

Date

SSN

Gender *

Male Female

Phone Number *

Please enter a valid phone number.

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Referral Source Information

Name of Person Making Referral *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Name of Medical Facility/Agency *

Does the person being referred have a family member or household member who is currently employed with TCMHS? *

Yes No Inknown

Reason For Referral *

Is the person you are referring having thoughts of hurting him/herself or somebody else at this time? (If yes, call Crisis Hotline: 1(888)568-1112 *

Yes No

State Disposition *

Is the person being referred a Class member? *

Yes No Unknown

Is the person being referred a veteran or has served in the military? *

Yes No Unknown

Is the person being referred an immediate family member of an individual in the military and/or a veteran? *

Yes No Unknown

Insurance/Paysource

Policyholders Name

First Name Last Name

Insurance Company

Policy ID#

Policy Group

Date of Birth:

Date

Policyholders SSN

Relationship to Consumer

Maine Care #

Medicare #

Self Pay

Potential Grant

Parental Rigths/Guardianship

The right to consent to treatment for children is exercised by the child/children's parent, guardian, or person who has that right assigned to them by a court of law. The following information is needed to determine the individual to consent to this child's treatment at Tri-County Mentasl Health Dervices.

Parent #1

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Does this person have parental rights?

Yes No

If yes:

Sole Shared Allocated

Parent #2

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Does this person have parental rights?

Yes No

If yes:

Sole Shared Allocated

Legal Guardian

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Is this based on:

Durable Power of Attourny Court Order

Requested Services

Adult Services

ACT (Assertive Community Treatment) see screening below Behavioral Health Home Co-Occurring Services (Mental Health/Substance Use) CRS (Community Rehabilitation Services) see screening below EMDR Opioid Health Homes Outpatient Counseling Psychiatric Services

Child Services

Behavioral Health Home EMDR MST (Multi-Systemic Therapy) MST - PSB (Problem Sexualized Behavior) Outpatient Counseling Psychiatric Services TF-CBT

Substance Use Services

Outpatient Counseling

Group Services:

DBT

If an Interpreter is needed, complete below:

Communications Method:

Primary Language:

Assertive Community Treatment (ACT)/Community Rehabilitation Services CRS Screening

Additional required information to process for ACT and CRS

Mental Health Diagnosis

In the last two years:

Have you been hospitalized in a State Psychiatric Facility?

Yes No

Have you had at least two psychiatric hospitalizations?

Yes No

If yes, where and when did this take place?

Have you lived in a group home for mental health reasons?

Yes No

Have you had any involvement in the legal system that is related to mental health?

Yes No

If yes, what was the involvement and how did it relate to mental health?

Have you ever been voluntarily hospitalized?

Yes No

If yes, when and where did this take place?

Has your housing been risky due to mental health?

Yes No

If yes, what was the risk? Are you homeless or have you been homeless due to mental health?

While participating in other services, have you been psychiatrically hospitalized, had legal involvement, or risked losing your housing?

Yes No

If yes, please explain.