Children Referral Form Children Referral Form Child Demographic InformationToday’s Date:* MM slash DD slash YYYY Individual Requesting Service* First Last Relation to Child* Service Location*30 Blueberry Rd. Portland, ME 0410212 Spruce St. Suite 5 Augusta, ME 04330Please select the closest location to the patient residential area:Child's Name:* First Last Child's DOB:* Month Day Year Race:* Gender:*MaleFemaleOtherPhone*Preferred Contact Method Phone Email Both Child's Primary Language:* Does the child's family needs an Interpreter?*YesNoLanguage Needed? type "N/A", if the above answer "No"* Child's current Address* 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 Legal Guardian Name:* First Last Legal Guardian Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Legal Guardian Phone*Legal Guardian Email* Guardian's Custody* Married Sole Shared, if shared fill in name/address below DHHS Own Shared Guardian Person Information, if selected aboveShared Guardian Name First Last Shared Guardian Address Street Address City State / Province / Region ZIP / Postal Code Shared Guardian PhoneHealth Insurance InformationHealth Insurance Company:* MaineCare Health Insurance ID:* Services Requested* Children Case Management Children Behavioral Therapy Mental Health QuestionsAny Hospitalization?* Yes No If yes what date? Month Day Year Is the child at risk to be hospitalized?* Yes No List of Symptoms:* Mental Health Diagnoses, if any: Source of Diagnoses: Other QuestionsThere are other agencies in the community that provide similar services to HOM.* I have looked other agencies in the community, but I prefer Hand of Mercy. I have not looked other agencies in the community, and I prefer Hand of Mercy. Referred by:* First Last Phone*Email* Relationship to the child? If legal guardian please type "legal guardian"* If provider, what organization?* Consent* I certify that the information submitted in this referral form true and correct to the best of my knowledge.PhoneThis field is for validation purposes and should be left unchanged.
