Get Referral Form Download Pdf - Tri-county Mental Health Services - Tcmhs

Filling out the Referral Form for Tri-County Mental Health Services is an important step in accessing necessary support. This guide will provide you with clear, step-by-step instructions to ensure that your form is completed accurately and efficiently.

Follow the steps to complete your referral form online.

1. Press the ‘Get Form’ button to obtain the Referral Form, ensuring it opens in your preferred editor.
2. In Section One, provide the consumer's identifying information. Fill in the last name, date of birth, contact number, and mailing address including street/apartment number, city/town, state, and zip code.
3. Proceed to Section Two and enter the consumer’s first name, middle initial, and social security number. Indicate the preferred contact number. Also, specify whether there is a family member or household member currently employed with TCMHS by selecting 'Yes' or 'No'.
4. In Section Three, clearly state the reason for referral along with any relevant risk factors. Indicate if there are thoughts of self-harm or harm to others. Mark whether the consumer is a class member and if they are a veteran or have served in the military.
5. Fill out Section Four regarding insurance/pay source information. Enter the policyholder's name, insurance company, policy ID, policy group number, date of birth, policyholder's social security number, and their relationship to the consumer. Specify if they are using Maine Care, Self Pay, Medicare, or any potential grant.
6. In Section Five, provide the names, addresses, and phone numbers of both birth parents. Indicate their marital status and whether guardianship is held by someone other than the birth parents. Include the name and contact information of the guardian if applicable.
7. Finally, in Section Six, outline the requested services, including any specific programs needed. If an interpreter is required, indicate the preferred communication method and primary language.
8. Once you have filled out all sections completely, check for accuracy and completeness. Save your changes, download the completed form, or print it for submission. You may also have the option to share the form if necessary.

Complete your referral form online today to take the first step towards accessing mental health services.