Cedar Haven Counseling, LLC

Cedar Haven Counseling, LLC

Referral Form
Welcome! Thank you for reaching out to Cedar Haven Counseling, LLC. Please complete this form to the best of your ability, so we can best serve you. At this time, we only accept MaineCare or private pay.
- Referred by (name / organization)*
- Relationship to Client*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Name*
  
  First NameLast Name
- Parent/Guardian
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Child/Adolescent CounselingAdult CounselingSubstance Use Disorder - Intensive Outpatient Program
- YesNo
- Disclaimer
  
  This referral form is for coordination and contact purposes only. Please do not include protected health information (PHI), clinical details, or sensitive personal information. Clinical and health-related information will be collected through a secure intake process.
- Should be Empty:

Disclaimer