Online Referral Form Online Referral Form Referral Location(Required)BangorWatervilleSelect Bangor or WatervilleIs the client enrolled in services with another provider at this time?(Required) Yes No If yes, then what service is being provided? How was the client referred to Cornerstone? Requested ServicesRequested Services(Required) Individual/Family Therapy Services Group Therapy Services Case Management Services Co-Occurring Services Medication Management Services Suboxone/MOUD Services SUD Counseling Services Psych Testing Services Other (Please specify) Other Service(s) Requested How would they like to receive services?(Required) In Office Telehealth (computer audio/visual) Telephonic (telephone only) Does the client require special accommodations? Yes (please describe) No Special Accommodations Required DiagnosisDoes the client have a mental health diagnosis? Yes No What is the diagnosis (if known)? Diagnosed by whom & when (if known) DemographicsName(Required) First Name Last Name Date of Birth(Required) 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 Phone NumberEmail Gender Male Female Transgender Non-binary Other (If applicable) Guardian/Legal Representative Guardian/Legal Representative must be present at first appointment. (If applicable) Are parents separated or divorced? Yes (we’ll need a copy of agreement) No (If applicable) Emergency Contact Name Relationship Phone Number InsurancePrimary 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?Service QuestionsHas the client recently had thoughts of harming self or others? Yes No Has the client been hospitalized in the past 30 days for mental health or substance use? Yes No If the client is seeking medication management or MOUD services, are they currently on any type of medication? Yes No Is the client pregnant? Yes No Was the client recently released from jail? Yes (probation paperwork on intake) No Does the client have a history of overdose? Yes No If yes, last occurance Is the client currently in withdrawl? Yes No Crisis and Counseling: 1-888-568-1112 Careline: 1-844-844-2622This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
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