Refer a Child

Complete the form below to refer a child for our services. We accept referrals from parents, schools, healthcare providers, and community agencies.

Referral Form

Child's Full Name *

Date of Birth *

Parent/Guardian Name *

Email Address *

Phone Number *

Home Address *

Referral Source *

Please select all services you're interested in:

Children's Case Management Section 28 Services Outpatient Therapy

Insurance Information

MaineCare Private Insurance No Insurance

MaineCare ID Number

Please describe the main concerns or needs *

Additional Information

Someone from our team will contact you within 1-2 business days after receiving your referral.