Client Referral

1. Referral Information

Date of Referral *

Type of Referral (check all that apply) *

Diagnostic Evaluation Outpatient Therapy Vineland Assessment Daily Living Skills (Section 17 DLS) Adult Case Management (Section 17 CIS)

2. Individual Being Referred

Full Name *

First Name

Last Name

MaineCare # *

Date of Birth *

Preferred Name (optional)

Gender (optional)

Mailing Address *

City *

State *

ZIP Code *

3. Contact Information

Name *

First Name

Last Name

Relationship to Individual (optional)

Phone Number *

Email Address *

Best Day/Time to Contact (optional)

Legal guardian name (if applicable) (optional)

Guardian phone number (optional)

4. Referral Source

Name *

First Name

Last Name

Role / Title (optional)

Organization / Program *

Email Address *

Phone Number *

5. Reason for Referral

Brief description of concerns (1-3 sentences) *

Current diagnosis (optional) We need a confirmation of eligibility letter before services can start. If you have it, attach it below.

Confirmation of eligibility letter (optional) Choose files No file chosen PDF, Word, Excel, text or image files — about 10 MB each, up to 10 files.

6. Safety & Risk Screening

Any current safety concerns? *

Yes No

History of self-harm or harm to others?

Yes No Unknown

7. Consent & Acknowledgement

Has the individual / legal guardian been informed of this referral? *

Yes No

Consent attestation *

I confirm that I have the authority, or the individual’s or legal guardian’s consent, to share this information with MC Community Services.