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Children's Behavioral Health Services

Referral Forms and instructions for accessing Children’s Behavioral Health Services: Section 24 Free Standing Day Habilitation, Section 65M/N, Section 13.12 Targeted Case Management

Contracted Provider Critical Incident Reporting Form   Microsoft Word* Adobe PDF*
 

Assessments
CAFAS Summary Scoring Sheet (Updated February 2008)   Microsoft Word* Adobe PDF*

CAFAS Scoring Sheets Instructions

   Microsoft Word* Adobe PDF*
PECFAS Summary Scoring Sheet (Updated February 2008)   Microsoft Word* Adobe PDF*
Assessment Exemption and/or Program Change Form   Microsoft Word* Adobe PDF*
FES score sheet   Microsoft Word* Adobe PDF*
 

Intensive Temporary Residential Treatment

     
Application for Intensive Temporary Residential Treatment   Microsoft Word*  
 

Release Information

Authorization to Release Information   Microsoft Word* Adobe PDF*
 

Grievance

      
Child or Adolescent Grievance Form   Microsoft Word* Adobe PDF*

Child or Adolescent Grievance Form Instructions

 HTML    
 

Child and Family Behavioral Health Services (Section 65 M/N)

MaineCare Section 65M&N Information and Forms HTML    
 

Case Manament Services ( Section 13.12)

Section 13.12 Referral Form (Updated January 2008)   Microsoft Word*  

Section 13.12 Referral Form - Instructions (Updated January, 2008)

   Microsoft Word* Adobe PDF*
CM- Change in Status Form (Updated January, 2008)   Microsoft Word*  

CM - Change in Status Form Instructions (Updated January, 2008)

   Microsoft Word* Adobe PDF*
Change in Status Codes (Updated January, 2008)   Microsoft Word* Adobe PDF*
 

Day Habilitation Services (Section 24)

     
Section 24 Referral Form (Updated January, 2008)   Microsoft Word*  

Section 24 Referral Form - Instructions (Updated January. 2008)

   Microsoft Word* Adobe PDF*
Change of Status Form for MaineCare Section 24 (January 2008)   Microsoft Word*  

24 Service - Change in Status Form Instructions (Updated January, 2008)

   Microsoft Word* Adobe PDF*
Change in Status Codes (Updated January, 2008)   Microsoft Word* Adobe PDF*

 

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