Referral Form

Referral

All Locations: 1(800)304-HOPE (4673)
In order to process your referral in a timely manner, please complete as much as possible.

Consumer Identifying Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN
Gender*

MaleFemale
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Source Information
Name of Person Making Referral*

First NameLast 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?*

YesNoUnknown
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*

YesNo
State Disposition*
Is the person being referred a Class member?*

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

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

YesNoUnknown
Insurance/Paysource
Policyholders Name

First NameLast Name
Insurance Company
Policy ID#
Policy Group
Date of Birth:

MonthDayYear
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 Mental Health Dervices.
Parent #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Does this person have parental rights?

YesNo
If yes:

SoleSharedAllocated
Parent #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Does this person have parental rights?

YesNo
If yes:

SoleSharedAllocated
Legal Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Is this based on:

Durable Power of AttournyCourt Order
Requested Services
Adult Services

ACT (Assertive Community Treatment) see screening belowBehavioral Health HomeCo-Occurring Services (Mental Health/Substance Use)CRS (Community Rehabilitation Services) see screening belowEMDROpioid Health HomesOutpatient CounselingPsychiatric Services
Child Services

Behavioral Health HomeEMDRMST (Multi-Systemic Therapy)MST - PSB (Problem Sexualized Behavior)Outpatient CounselingPsychiatric ServicesTF-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. In order to qualify for section 17 services you need to have at least 2 psychiatric hospitalizations within the last two years
Primary mental health diagnosis
Mental health diagnosis in the last 2 years
Have you been hospitalized in a State Psychiatric Facility (Riverview or Dorothea Dix Psychiatric Center)?

YesNo
Have you had at least two psychiatric hospitalizations?

YesNo
If yes, where and when did this take place?
Have you lived in a group home for mental health reasons?

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

YesNo
If yes, what was the involvement and how did it relate to mental health?
Have you ever been involuntarily hospitalized?

YesNo
If yes, when and where did this take place?
Has your housing been at risk due to mental health?

YesNo
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?

YesNo
If yes, please explain.
What other providers do you currently have?
Should be Empty: