Referrals

Currently waitlisted for new patients.

Most major insurances accepted.

We are currently waitlisted for new patient. If you would like to join the waitlist, you can submit a request below and you will be contacted when there is availability.

To refer a yourself, a loved one, or a client for mental health treatment, complete and submit the form below.

If you would prefer to fax a referral, please use this link to download a Provider Referral Form.

Fax completed forms to (207) 510-8006

Referral Form

Name

First Name

Last Name

How can we help?

Date of Birth

MM

DD

YYYY

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Parent/Legal Guardian (if applicable)

First Name

Last Name

Current Diagnoses (if known)

Do you prefer in-person or telehealth?

Insurance Provider

Member ID

Subscriber's Name

First Name

Last Name

Who is referring (if different from self)

Referring Provider/Practice Contact Information

Phone

(###)

###

####

Fax

(###)

###

####

Email

Currently waitlisted for new patients.

Most major insurances accepted.

Referrals

Referral Form

Questions before getting started? Get in touch.