Adults Referral Form Adult Referral Form "*" indicates required fields { Main Office: 30 Blueberry Rd, Portland, ME 04102 } Tel: (207) 747-5226 Fax: (207) 810-2016 [email protected] www.homhealthcare.org Today’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 Demographic InformationPatient Name:* First Last DOB:* Month Day Year Gender:*MaleFemaleOtherRace:*Hispanic/Latino*YesNoMarital 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 Other Health Insurance ID:*If Grant, type N/AServices Requested*Click here to selectCase Management*Click here to select another service if neededCounseling/Outpatient TherapyPatient Safety QuestionsAny 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 Other Is the patient at risk of being homeless?* Yes No Other Is the patient at risk to be jailed?* Yes No Other Is there a recent clinical assessment?* Yes No Not Sure Other List of Symptoms:*Mental Health Diagnosis, if any:Source of Diagnoses:Is the patient currently in substance abuse treatment?* Yes No Not Sure Other If yes, what's the agency name?What's the substance abuse agency phone number?Is the patient currently receiving services?* Yes No Not Sure Other If yes, are you in process of canceling the service?* Yes No Not Sure Other Have you submitted a referral for case management service with another agency?* Yes No Other Health Issues QuestionsDoes the patient have a physical disability?* Yes No Unknown Does the patient have dental needs?* Yes No Unknown If yes, please explain: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.CommentsThis field is for validation purposes and should be left unchanged.
