KBH - Referral

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Once you submit this referral, an Access Center Specialist will reach out to review the referral with the client or guardian. If you have any questions about the status of the referral, please call 207-873-2136, option #3 for new client services. You may also visit one of our four clinics during normal business hours to meet with one of our Access Center Specialists in person.

Referral Information

First Name

Middle Name

Last Name

Date of Birth

Gender

Male

Female

Unknown

Preferred Language

Emancipated Minor?

Yes

No

Office site to be seen

Does this person have a legal guardian (such as a foster parent or in-home care provider)?

Yes

No

Mailing Address

Street 1 Apt

Street 2

City, St Zip

Physical Address

Street 1 Apt

Street 2

City, St Zip

Phone Numbers

Home x

Primary

Notes

Work x

Primary

Notes

Cell x

Primary

Notes

Fax Number

Caregiver Information

First Name

Middle Name

Last Name

Suffix

Comments

Date of Birth

This person is the Primary Caregiver for this client

This person is the Emergency Contact for this client

This person is the Legal Guardian for this client

Caregiver Address

Street 1 Apt

Street 2

City, St Zip

Caregiver Phone Numbers

Home Notes

Work Notes

Cell Notes

Services Requested

Clinic Services

Community Services

Need to make a referral for these services? Please call our office at 207-873-2136, option #3 for more information.

Augusta House
Children's Home & Community based Treatment
Community Rehabilitation Services
Valley View
Walnut
Wilson Place
Young Adult PNMI
Multisystemic Therapy
Multisystemic Therapy - Problem Sexual Behavior

Referring Party

Name

Phone Number

Phone Extension

Fax Number

Street Line 1

Apartment/Suite

Street Line 2

City, St Zip

KBH Referral Forms

Once you submit this referral, an Access Center Specialist will reach out to review the referral with the client or guardian. If you have any questions about the status of the referral, please call 207-873-2136, option #3 for new client services. You may also visit one of our four clinics during normal business hours to meet with one of our Access Center Specialists in person.