HEALTHY HEALING

COUNSELING, INC.

Adult Case Management Referral Form

Client's Full Name(*)

Please let us know your name.

Date of Birth

/ / Invalid Input

Gender

MaleFemale Invalid Input

Class Member

YesNo Invalid Input

Address

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School

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Home Phone

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Permission to Leave a Message

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Guardian Name

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Guardian Home Phone

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Guardian Cell Phone

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Guardian School

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Language Spoken by Client

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Interpreter Needed for Client

YesNo Invalid Input

Interpreter Needed for Guardian

YesNo Invalid Input

Referral Source Name

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Referral Organization

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Referral Phone

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Referral Email Address

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Client's Reason for Seeking Case Management (Symptoms/Service Needs)

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Safety Concerns (Domestic Violence, Anger/Aggression)

YesNo Invalid Input

Substance Abuse

YesNo Invalid Input

If Yes to Substance Abuse, Please Specify

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Legal Issues

YesNo Invalid Input

Is the Client in Crisis?

YesNo Invalid Input

Was Crisis Information Given?

YesNo Invalid Input

Case Management Preferences

MaleFemale Invalid Input

Case Management Request

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Current Diagnosis: Axis

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Current Diagnosis: GAF

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Diagnosing Clinician

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Date of Current Diagnosis

/ / Invalid Input

If No Current Diagnosis - Assessment Needed

YesNo Invalid Input

Clinician Assigned To

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Insurance Information

MaineCare Identification Number

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Please verify you are human(*)

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"You can't change what's going on around you until you start changing what's going on within you" - - Author Unknown

Contact Us

Healthy Healing Counseling, Inc.

166 Old Waterville Rd, Suite 1
Oakland, Maine 04963

Phone (207) 465-9001
Fax (207) 716-1474

Email Us