Referral Form Logo

  • Referral Form

  • Client Information

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  • Referral Source Information

  • Diagnosis Information

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  • If a client is being referred to Case Management services, a qualifying diagnosis is required. The staff member completing the referral should ensure that the client signs a Release of Information (ROI) form for their diagnosing provider. This allows Thrive to contact the provider directly to obtain verification of the diagnosis.

  • Authorization for Release of Information

  • AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

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  • I , hereby authorize Thrive-Maine Behavioral Health LLC to obtain/receive my information:

  • Information to be RECEIVED FROM/DISCLOSED TO:

  • If I have been diagnosed or treated for any of the following, I understand that Thrive Behavioral Health needs my consent to disclose related information. In no event may any such information, if applicable, be disclosed without my specific consent.

  • I * authorize disclosure of information which refers to treatment of diagnosis of drug or alcohol abuse (Federal drug & alcohol regulations, 42 CFR 2.31). Such information may not be disclosed by the recipient without my specific written consent.

  • I *authorize release of any information that may relate to diagnosis/treatment for HIV, ARC, or AIDS.

  • I *authorize release of any information that may relate to mental health treatment.

  • I authorize the above-named provider to make subsequent disclosures to the same recipient pursuant to this authorization. Unless earlier revoked, this consent expires in 90 days or on the following date not to exceed one (1) year.

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  • I understand that the above information may be covered by the rules of the Department of Health and Human Services (the “Rights of Recipients of Mental Health Services” or the “Rights of Recipients of Mental Health Services Who Are Children In Need of Treatment”). Per company policy, Thrive Behavioral Health will NOT release information created by other practitioners or facilities. Statements added to records by clients and/or guardians will not be released without written consent.


    I understand that I may cross out any words on this form with which I disagree, and that I may revoke this authorization at any time by written request.


    I understand that the information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving person or organization and, upon re-disclosure, may no longer be protected by federal privacy laws.


    I understand the matters discussed on this form. I release the Provider, its employees, officers, and medical staff, and business associates from any legal responsibility, or liability for the disclosures of the above information to the extent indicated and authorized herein.

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