Online Referral Form Online Referral Form Referral Location(Required)BangorWatervilleSelect Bangor or WatervilleServices Being Requested Name(Required) First Name Last Name Date of Birth MM slash DD slash YYYY Current Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GenderMaleFemaleInsurancePrimary Insurance Name of Guarantor First Last Policy Number Group Number Insurance PhoneSecondary Insurance Name of Guarantor First Last Policy Number Group Number Insurance PhoneReason for Services?Do you or have you ever had thoughts of suicide? Yes No Have you ever acted on these thoughts? Yes No Do you have the Crisis and Counseling Phone Number? Yes No The Crisis and Counseling phone number is 1-888-568-1112.On a scale of 1 – 10 (Example: Depression, anxiety, etc.) where would you say that you have been in the past month?Please enter a number from 1 to 10.1 is doing the best while 10 is doing the worstGeneral InformationParent/Guardian/Emergency Contact? Yes No Mother's Name First Last Mother's PhoneMother's Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Name First Last Father's PhoneFather's Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian's Name First Last Guardian's PhoneGuardian's Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian/parent MUST be present at first appointment. Are the parents divorced or separated? Yes No If applicable, we will need a copy of the divorce or custody agreement at the time of the initial appointment. Without said agreement, both parties will have the right to information regarding the client. Cornerstone does not get involved in custody disagreements regarding finances. If the client is a child, where is the child currently residing? Is the client an AMHI Consent Decree Member? Yes No Client's primary care provider (MD, PA)Name PhoneFax(if available)Does the client currently have any other services provided? Yes No (i.e. Case Manager, Probation, etc.)Service Provider's Name PhoneFax(if available)Second Service Provider's Name PhoneFax(if available)Have you ever received mental health services before? Yes No Mental Health Provider's Name PhoneFax(if available)Second Mental Health Provider's Name PhoneFax(if available)Has the client been hospitalized in the past 30 days for mental health or substance abuse? Yes No Hospital or Inpatient Unit client was admitted to Location of Admission Length of Stay Does the client have a mental health diagnosis? Yes No What is that diagnosis? Diagnosed by Whom? Is the client currently on any type of medication? Yes No (Please bring info to first appointment)Does the client have their own transportation? Yes No How will transportation be provided? Does the client require special accommodations? Yes No Please DescribeHow was the client referred to Cornerstone? Is there anything else you would like Cornerstone to know about you? Yes No What else would you like Cornerstone to know about you?This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.NameThis field is for validation purposes and should be left unchanged.
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