Forms & Documents

Referrals & Statements

It is easy to make a referral, as a professional or individual, with our online referral program. If you prefer to make a referral by phone, please call our Access Center at 1-888-322-2136 (toll-free).

If you are having any issues with making a referral or using a referral form, please contact afitts@kbhmaine.org.

Physician Referral Form

MST Referral Form

HCT Referral Form

Orientation Manual

HIPAA Consent of Treatment

Complaint/Grievances Form

Central Access Form

KBH Housing Application

Request for Recovery Coaching

Nondiscrimination & Accessibility Statement

Notice of Privacy Practices

Fair Housing Policy

Policy 4005: Fair Housing Practices

All proposed housing development activities or properties managed by Kennebec Behavioral Health will comply with the following statutory and regulatory citations:

Federal Fair Housing Act: Title VIII of the Civil Rights Act of 1968, as amended by the Fair housing Amendment Act of 1988, 42 U.S.C. 3601 et seq.

Federal Regulations Implementing the Fair Housing Amendments Act of 1988, Federal Register Vol. 54, No. 13, Monday, January 23, 189, 24 C.F.R. Part 14 et seq.

State Fair Housing Laws: Subchapter IV of the Maine Human Rights Act 5 M.R.S.A. 4551 et seq.

Facilities for homeless persons will adhere to the McKinney-Vento Homeless Assistance Act with respect to education services and designated staff to assist with eligibility and linkage. Those with Homeless status who are identified as youth or young adults (18-24) under HUD rule will be evaluated for eligibility and need for McKinney-Vento support for educational needs.

In addition to the above, Kennebec Behavioral Health will adhere to the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973.

Release of Information (ROI) Forms

To obtain a release of information, or ROI, please contact our Medical Records team.

Waterville:
Phone:207-873-2136
Fax: 680-4016
ROI Form

Augusta
Phone: 207-626-3455 or 207-213-2037
Fax: 626-7597
ROI Form

Skowhegan:
Phone: 207-474-8368
Fax: 474-9029
ROI Form

Winthrop:
Phone: 207-377-8122
Fax: 248-8538
ROI Form

Farmington
Phone: 207-860-3026
Fax: 707-1697
ROI Form

DHHS Forms

For Maine DHHS referrals only:
Consider entering your referral directly online in our secure Access entry system. For more information about this confidential site and to register, please contact Amanda Fitts at afitts@kbhmaine.org.

DHHS Office of Child and Family Services Referral Checklist

Department of Corrections Forms

For Maine Dept. of Corrections referrals only:
Consider entering your referral directly online in our secure Access entry system. For more information about this confidential site and to register, please contact Amanda Fitts at afitts@kbhmaine.org.

Department of Corrections (DOC) Referral Checklist