Case Number: _____________________
Case Manager Assigned:___________________________

Date Referral Received: __________________  
Referral received by:  Fax    Phone    Mail    E-Mail

Child’s Name:________________________________________________        Date of Birth:___________
Address:____________________________________________________        Gender:   M______ F______
Town: ____________________________________________   State:__________        Zip code _________
Social Security#__________________   Maine Care#_____________________ Does child have Maine Care?  Y / N
Does the child have any known allergies?  Y/N ______  If yes, explain:____________________________________
Child’s custody status:__________________________________________________________________________
Parent/Caregiver Name(s) ______________________________________________________________________
Address: _____________________________________________________________________________________
Town:_______________________________________________  State______________  Zip code_____________
Phone Number__________________________    Alternate Phone Number________________________
Are there safety concerns? (DV, anger, aggression, substance abuse, etc.)  Yes____  No____  If yes, specify:______
__________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________

Referent: _______________________________ ___ Relationship to Client:________________________________
Address:_______________________________________________________ Town:_______________________ 
State:_____      Zip code:____________    Contact#_________________________________

Diagnosis, GAF/CGAS:___________________________________________________________________________   
Date of Last Evaluation:___________   Name of Evaluator:_____________________________________________
Primary Care Provider:__________________________________________  Phone:__________________________
Presenting Problem/Reason for referral:____________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Is client in crisis?   Yes_____ No____   Was crisis information provided to the family? Yes_______   No______