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 Year Race:* Hispanic/Latino*YesNoGender:*MaleFemaleOtherMarital Status*SingleSeparatedMarriedDivorcedWidowedPhone*Patient Email Preferred Contact Method Phone Email Both Language:* 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 Grant Health Insurance ID:* If Grant, type N/AServices Requested* Case Management Counseling/Outpatient Therapy Patient Safety QuestionsClass Member? "AMHI Consent Decree"* Yes No Any substance abuse?* Yes No Is patient in crisis?* Yes No Does the patient understands they have been referred for this service?* Yes No Does the patient understands what to expect from this service?* Yes No Mental Health QuestionsAny Hospitalization?* Yes No If yes what date? Month Day Year Is 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 Unknown If yes, please explain: Does the patient have dental needs?* Yes No Unknown If 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.NameThis field is for validation purposes and should be left unchanged.
