Groundwork Healing, LLC Assessment Referral Form

  • Groundwork Healing, LLC Assessment Referral Form

    This form is to be completed by an agency or organization referring a client for a sexual abuse risk assessment, or a mental health and/or violence risk assessment. Please note that individual and group therapy services do not require a referral, and this form cannot be used as such.

  • After Groundwork Healing receives your referral, our team will contact the referring source and/or the client to discuss next steps. We aim to review and process all assessment referrals within 1–2 weeks.

    Please note: Wait times may vary depending on the volume of referrals received, the type of assessment requested, and clinician availability. 

    Additional documentation is required to process this referral. Required documents will be outlined at the end of this form and must be submitted to our office via fax at (207) 941-0880. Referrals will not be reviewed or processed until all requested documentation has been received.

  • Referring Entity Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Client Information

  •  - -
  • Format: (000) 000-0000.

  • Assessment Information

  • Please note: a sexual abuse risk assessment is a standalone assessment and cannot be combined with any other type of assessment. If a sexual abuse risk assessment is required in addition to a mental health assessment and/or a violence risk assessment, separate referral forms must be completed for each assessment.

  • Please note that we cannot provide neuropsychological, psychological, or substance use assessments/evaluations, nor can we provide CODE or Level of Care assessments.

  • Please note that record review and report writing fees are not covered by insurance. If the referring entity is responsible for associated fees, our office will contact you prior to scheduling to obtain payment authorization. 

  • Referral Documentation

  • Please submit documentation related to the case, including but not limited to the following, to Groundwork Healing, LLC via fax at (207) 941-0880:

    • DHHS case notes
    • Notices of Substantiations and/or Indictments
    • Child Preliminary Protection Orders
    • Protection from Abuse and/or Harassment Orders/documentation
    • Court documentation (docket records, notice of hearings, jeopardy orders, etc.)
    • Police records
    • Criminal history records
    • Motor vehicle records

    We understand that these documents do not apply to all cases/clients, but the more our providers have to review, the more comprehensive their assessment can be.

     

  • Assessment referrals will not be processed without the above documentation.

     

    By signing below, I acknowledge that this assessment referral will not be processed by Groundwork Healing, LLC until the required collateral documentation is received via fax at (207) 941-0880. I understand that emailed client information will not be accepted by Groundwork Healing, LLC.

  •  - -

  • By signing this document, you acknowledge that the information provided is accurate to the best of your knowledge and that you consent to the processing of this referral in accordance with Groundwork Healing LLC's policies.

  •  - -
  • Should be Empty: