Referral form

Begin Your Referral

Tell us about the person you're referring.

Take a few minutes to share what we need to follow up. Required fields are minimal — leave the rest if you're unsure, and we'll cover them on our first call.

Which program(s) are you requesting?

Targeted Case Management
Community Support Services
Outpatient Therapy

Phone needs you

Your relationship to the person being referred

If you are referring someone else: your name, organization, and phone

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of Birth

Briefly describe the needs you have that you expect assistance from the above program(s) with:

A short summary is enough. Please do not include diagnoses, medications, or detailed medical history here. We will go over that privately on our first call.

Do you have any other documents you would like to upload for us?

Privacy & Consent

I agree that Amana Care may use the information in this form to review this referral and contact me about services. I understand it will be kept confidential and shared only with Amana Care staff involved in intake.

You can request a copy of our Notice of Privacy Practices by calling (207) 401-4349.

Tell us about the person you're referring.

Referral Form

Adult and Child Services Referral Form