Referrals

Want to make a referral but prefer to speak with us first? Fill out our short referral form.

Call our Referral & Intake QuickConnect Line for more information or to make a referral. After referral is completed, it will be assigned to staff as appropriate. Our referral process is a simple phone call that takes 5-10 minutes. Intake will be scheduled at the same time and our goal is to have intake completed within 1 week of referral!

Call Quick Connect at 453-4367 or 1-800-781-8550 ext. 2722
or, fill out our referral form below and we will contact you within 72 hours.

You may also download a copy of the referral form here, and email it to [email protected].

There was a problem with your submission. Please correct the issues below

Your Information

Your Name *:

Your Phone # *:

Your Email *:

How did you hear about us?:

Basic Child Information

Youth name:

Gender: Male
Female

Date of birth:

Age:

MaineCare #:

Parent Information

Parent Name:

Address:

Phone #: Best number to call

Guardian Information

(If applicable)

Guardian name:

Address:

Phone #: Best number to call

Referral Information

Referral source: Include Provider Name, Agency Name, Address & Phone #

Child Information

Is the child currently receiving Case Management or BHH services?: Yes
No

Diagnoses:

School name:

School grade:

Is the child receiving Special Education services?: Yes
No

What's going on?: How are things at home, school, etc.

Are there any developmental delays: (speech, social skills, toileting) If yes, please explain:

Have there been any emergency/crisis issues recently? If yes, please explain:

What can our services do to help? : Make referrals, school support, behavior management, etc.

Is there currently DHHS involvement? If yes, please explain:

Please check the box below before submitting.

Funded by State of Maine Department of Health and Human Services (DHHS) and MaineCare.