Case Management Referral Form
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2Case Management Referral Form
Page 1
Please fax the following information to: Renee or Paula at 333-3037
Client Full Name:
Date of Birth:
Gender: M /F
Class Member: Y / N
Address:
School:
Home Phone:
Cell Phone:
Permission to leave a message: Y / N
Guardian name:
Home phone:
Cell number:
School:
Language spoken by client:
Interpreter Services needed: Client: Y / N Guardian: Y / N
Referral source name:
Organization:
Phone:
Email Address:______________________________________________________________________________________________________________________
Symptoms / Service Needs:
Client’s reason for seeking Case Management
Safety concerns (Domestic Violence, Anger/Aggression): Y / N
Substance Abuse: Y / N
If Yes, please specify:
Legal Issues: Y / N
Is the client in crisis? Y / N
Was crisis information given? Y / N
Case Management preferences: Male / Female
Requesting:
Current Diagnosis: Axis I______________________________________________________________________ GAF _____________________________
Diagnosing Clinician: ________________________________________________________
Date of current diagnosis: ________________
**(If you are the diagnosing clinician, please complete page 2 of this referral form**)
If no current diagnosis – Assessment needed: Y / N
Clinician Assigned to:__________________________________________
Insurance Information
Mainecare Identification Number:
Social Security Number:
OFFICE USE ONLY
Date Referral Received:
Date Insurance Verified:
Initials:
Full Mainecare: Y / N
Case Manger Assigned:
Date:
Please note: Insurance was verified on the date listed above through the Mainecare verification line. The clinician
who accepts this referral assumes responsibility for verifying this information with the client and with Insurance
Company at start of services and no less than once monthly.
03.25.15 Case Management Ref Form
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