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)
   Microsoft Word* Adobe PDF*
Application to Become a CBHS Contracted Service Provider
  • Form
   Microsoft Word* Adobe PDF*
    • Instructions and Additional Requirements For Proposals of Waiver Section 32
   Microsoft Word*  
Contracted Provider Critical Incident Reporting
  • Form
  Microsoft Word* Adobe PDF*
Individual Planning Funding Application
  • Individual Planning Fund Form (This service is not an entitlement and is subject to availability of funds)
   Microsoft word*  

Instructions

   Microsoft Word* Adobe PDF*
  • W-9 Request for Taxpayer Identification Number and Certification
    Adobe PDF*
Grievance
  • Child or Adolescent Grievance Form (This guide includes the instructions and the form to file a grievance)
   Microsoft Word* Adobe PDF*
Home and Community Based Treatment HCT
  • Information and Forms
 HTML    
Intensive Temporary Residential Treatment
  • Intensive Temporary Residential Treatment (ITRT) process
 HTML Microsoft Word*  
  • Application for Intensive Temporary Residential Treatment
   Microsoft Word*  
Release Information
  • Authorization to Release Information
   Microsoft Word* Adobe PDF*
Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations (RCS 28)
  • Information and forms
 HTML    
Statewide Individual Planning Funds for Outpatient & Medication Management Services
  • Form
   Microsoft Word*  
  • Policy
   Microsoft Word* Adobe PDF*
Targeted Case Management
  • TCM Rule Guidelines
   Microsoft Word* Adobe PDF*
  • TCM Face To Face Contacts
   Microsoft Word* Adobe PDF*
  • Clarification Of Procedural Changes to TCM
   Microsoft Word* Adobe PDF*
  • Explanation of TCM Waitlist Process
   Microsoft Word* Adobe PDF*