Adults Referral Form Patient Demographic InformationToday’s Date:* MM slash DD slash YYYY Service Location*30 Blueberry Rd. Portland, ME 0410212 Spruce St. Suite 5 Augusta, ME 04330Please select the closest location to the patient residential area:Patient Name:* First Last DOB:* Month Day YearRace:*Hispanic/Latino*YesNoGender:*MaleFemaleOtherMarital Status*SingleSeparatedMarriedDivorcedWidowedPhone*Patient Email Preferred Contact Method Phone Email BothLanguage:*Interpreter Need?*YesNoAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact* First Last Phone*Relationship to the patient?*Health Insurance InformationHealth Insurance Company:* MaineCare Health Insurance ID:*Services Requested* Case Management Counseling/Outpatient TherapyPatient Safety QuestionsClass Member? "AMHI Consent Decree"* Yes NoAny substance abuse?* Yes NoIs patient in crisis?* Yes NoDoes the patient understands they have been referred for this service?* Yes NoDoes the patient understands what to expect from this service?* Yes NoMental Health QuestionsAny Hospitalization?* Yes NoIf yes what date? Month Day YearIs the patient at risk to be hospitalized?* Yes No Is the patient at risk of being homeless?* Yes No Is the patient at risk to be jailed?* Yes No Does the patient have an up to date clinical assessment?* Yes No Not Sure List of Symptoms:*Mental Health Diagnosis:Source of Diagnoses:Is the patient currently in substance abuse treatment?* Yes No Not Sure If yes, what's the agency name?What's the substance abuse agency phone number?Is the patient currently receiving case management service?* Yes No Not Sure If yes, are you in process of canceling the service?* Yes No Not Sure Have you submitted a referral for case management service with another agency?* Yes No Not Sure Other Health Issues QuestionsDoes the patient have a physical disability?* Yes No UnknownIf yes, please explain:Does the patient have dental needs?* Yes No UnknownIf yes, please explain:Referred by:* First Last Phone*Email* Relationship to the patient? If self please type "Self"*If provider, what organization? if not applicable type "N/A"*I understand* HOM will attempt to contact the patient two times only. Patients are responsible to update HOM with their current contact information. Consent* I certify that the information submitted in this referral form true and correct to the best of my knowledge.Untitled First Choice Second Choice Third ChoiceNameThis field is for validation purposes and should be left unchanged.