Referral forms and documents

For general referrals (that is, not from Maine DHHS or Department of Corrections employees)

Primary Care Physician referral form: Word document A note to Primary Care Physicians: We have expanded our web-based referral capabilities that results now in the fastest way to submit a complete referral. For more information about this, or to become a registered user, please e-mail Amanda Fitts at afitts@kbhmaine.org.
Central access form: Word document
Orientation manual: pdf
Nondiscrimination and Accessibility Statement: pdf
Orientation intake consent for treatment: Word document
HIPAA consent for purposes of treatment, payment and operations: Word document
Compliments Kudos Form Download and e-mail to info@kbhmaine.org
Complaint/Grievance Form: Instructions; Form
Release-of-information forms
Notice of privacy practices: Word document
Multisystemic Therapy (MST)
- Referral screening form: Word document

Children's Home and Community-Based Treatment (HCT)
- HCT program description: Word document
- HCT referral form: PDF document

For Maine DHHS referrals only:
Consider entering your referral directly online in our secure Access entry system. For more information about this confidential site and to register, please contact Amanda Fitts at afitts@kbhmaine.org.

DHHS Office of Child and Family Services referral checklist: Word document
Orientation manual: pdf document
Orientation intake consent for treatment: Word document
HIPAA consent for purposes of treatment, payment and operations: Word document
Release-of-information forms
Notice of privacy practices: Word document
Multisystemic Therapy (MST) referral form: Word document

For Maine Dept. of Corrections referrals only:

Department of Corrections (DOC) referral checklist: Word document
Central access form: Word document
Orientation manual: pdf document
Orientation intake consent for treatment: Word document
HIPAA consent for purposes of treatment, payment and operations: Word document
Release-of-Information forms
Notice-of-privacy practices: Word document
Multisystemic Therapy referral form: Word document

Housing forms:

General-informational documents

Standards of Conduct/Corporate Compliance Program

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Referral forms and documents