Children's Behavioral Health - Forms

Forms and instructions for accessing Children’s Behavioral Health Services:  MaineCare RCS (Rehabilitative and Community Support Services);
MaineCare  HCT(Children’s Home and Community Based Treatment)

Assessments

• CHAT (Children's Habilitation Assessment Tool) (revised 01/24/2011) (Word* | also in PDF*)

Application to Become a CBHS Contracted Service Provider

• Form  (Word* | also in PDF*)
  • Instructions and Additional Requirements For Proposals of Waiver Section 32 (Word*)

Contracted Provider Critical Incident Reporting

• Form (Word* | also in PDF*)
• For More Information Contact: Nadine Martin  Phone: 624-7944

Individual Planning Funding Application

• Individual Planning Fund Form (This service is not an entitlement and is subject to availability of funds) (Word*)
  • Instructions (Word* | also in PDF*)
• State of Maine Substitute W-9 & Vender Authorization Form
  • Printable Form (PDF*)
    • Instructions (also in PDF*)

Grievance

• Child or Adolescent Grievance Form (This guide includes the instructions and the form to file a grievance) (Word* | also in PDF*)

Home and Community Based Treatment HCT

• Information and Forms

Intensive Temporary Residential Treatment

• Intensive Temporary Residential Treatment (ITRT) process (also in Word*)
• Application for Intensive Temporary Residential Treatment(Word*)

OQMHP-PNMI

• Training record (Word* | also in PDF*)

Release Information

• Authorization to Release Information (Word* | also in PDF*)

Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations (RCS 28)

• Information and forms

Targeted Case Management

• TCM Rule Guidelines (Word* | also in PDF*)
• TCM Face To Face Contacts (Word* | also in PDF*)
• Clarification Of Procedural Changes to TCM (Word* | also in PDF*)
• Explanation of TCM Waitlist Process (Word* | also in PDF*)