Provider Forms

• Application For Emergency Involuntary Admission To A Psychiatric Hospital (PDF) 03/01/2021
• Notification To Judicial Officer Of Identification Of Psychiatric Hospital (PDF) 03/01/2021
• Involuntary Hold Notification Form
• Application to District Court for Involuntary Commitment to a Mental Hospital and Request for Involuntary Treatment (Word) | also as PDF
• Motion and Order for Transfer, MH 109 (for use after application for hearing is filed but before hearing is held) (Word) | also as PDF
• Motion and Order for Dismissal MH 106 (Word) (for use after application for hearing is filed but before hearing is held) | also as PDF
• Application to District Court for Involuntary Commitment to a Mental Hospital (Word) | PDF
  • Memo to Providers July 07, 2006 re: Application to District Court for Involuntary Commitment to a Mental Hospital (Word) | PDF
  • Model Form-CON for Psychiatric Hospitalization (24-hour certificate) (Word) | PDF
• Request and Endorsement for Transfer, MH 101 (for use during blue paper period) (Word | PDF
• Grievance Process Guide (PDF)

What is the SUPRT Survey?

The Substance Abuse and Mental Health Services Administration (SAMHSA) awarded Maine the State Opioid Response (SOR) grant to expand treatment and recovery services to individuals with opioid and stimulant use disorders. A requirement of the SOR grant is to administer SAMHSA’s Unified Performance and Reporting Tool (SUPRT) to program participants receiving grant-funded treatment and recovery services.

The SUPRT survey is a tool that collects data on a client’s behavior and activities. This tool sets performance goals and measures participant outcomes and progress in the enrolled program. It helps examine the effectiveness of the services provided to participants and helps the federal government assess the efficacy of how funding is being utilized. All SUPRT surveys are de-identified.

* Intake = date the participant began receiving grant-funded services.

**6-month and annual surveys completed outside the timeline do not meet SAMHSA survey requirements.

Implementing SUPRT Surveys

• SUPRT Survey Links: Each provider is given individualized links to online baseline, 6-month, annual, and closeout surveys.
• Maine SOR Grant SUPRT Implementation Guide (PDF): A guide for implementing the SUPRT survey in your organization.
• SUPRT Participant Tracking Sheet (Excel): A recommended tool for providers to track SUPRT surveys which have been completed, when follow-up surveys are due, and when participants have been removed from grant-funded services.

Performing GPRA Surveys

• Maine SOR Grant SUPRT Question by Question Guide (PDF): A guide to the intent and response options for each question found in SUPRT surveys.
• Maine SOR SUPRT Frequently Asked Questions by Participants (PDF): Created for use by participants, this guide answers commonly asked questions about the survey and its use.

Any questions regarding SUPRT should be directed to the Maine SOR Data Coordinator at GPRA@maine.gov.

• Request for Waiver of Reporting Requirements for Main Prescription Monitoring Program (PDF)
• E-Prescribing Waiver and Policy for Pharmacies (PDF)
• E-Prescribing Waiver and Policy for Individuals (PDF)

The Office of Behavioral Health is no longer accepting submissions of Critical Incident Reports via fax, email, mail, etc. Organizations that do not currently use the Kepro Atrezzo portal should contact Kepro’s provider relations staff at (866)521-0027, Option 1 or email ProviderRelationsME@Kepro.com. Kepro hours of operation are Monday thru Friday 8am to 6pm. Failure to proactively set up a login is not an acceptable reason for late submission of a CIR. Phone notification within 4 hours of learning of a Level 1 incident are still required; the phone number for notification is now (866)521-0027, option 6.

• Kepro Atrezzo