MEIRS Central Referral Form
Our Central Referral Form serves as a unified entry point to connect individuals and families with the comprehensive services offered by Maine Immigrant and Refugee Services (MEIRS).
Whether you're referring yourself or someone else, this form helps ensure clients are matched to the most appropriate services. Please fully complete the referral to avoid delays in processing.
Note that some services may require additional referral forms or documentation. Our intake staff will reach out to you or the client within 24 hours of submission to follow up and complete the intake process.
Referrer Information
Is this an urgent referral?
Please select...
Yes
No
Please state the reason:
Are you submitting this form on behalf of yourself?
Please select...
Yes
No
Referrer First Name
Referrer Last Name
Referrer Email
Referrer Phone
Referrer Organization/Affiliation
Client Information
First Name
Last Name
Date of Birth
Gender
Cell
Street Address
Street Address 2 (Apt/PO Box)
City
State
Zip Code
MaineCare #
Other Insurance Information
Primary Language
Other Language Name
Is the client a class member?
Please select...
Yes
No
Unknown
Is the client under 18 or under legal guardianship?
Please select...
Yes
No
Parent/Legal Guardian(s) Information
For services to begin for children, a consent is required by either a parent or guardian. Please complete the following information. Proof of legal guardian documentation will be required.
Parent/Legal Guardian
First Name
Last Name
Street Address
Street Address 2 (Apt/PO Box)
City
State
Zip Code
Cell Phone
Relationship Type
Additional information about Parent/Legal Guardian
(Please indicate if there is shared custody, no contact with a parent, etc.)
Proof of Legal Guardianship Documentation
Reason for Referral
Please explain the reason for referral as much detail as possible (Mental health concern, behavioral issues, social and school issues, etc.)
Is client currently receiving services anywhere else?
Please select...
Yes
No
Unknown
Please describe services including agency and staff working with the client.
Mental Health Diagnosis
Does client have current mental health diagnosis?
Please select...
Yes
No
Unknown
Current Mental Health Diagnosis
Diagnosed by (Name and Credential)
Date Diagnosed
Service(s) Requested
Note: Some services may require additional referral form(s) or documentation.
Select Services
Please select...
Targeted Case Management (Children Case Management)
Community Support Services (Adult Case Management)
Outpatient Counseling (Adult and Children)
Diagnostic Assessment (Adult and Children)
Rehabilitative & Community Support Services (Section 28, Children Only)
Home & Community Treatment (HCT, Section 65, Children Only)
Youth Programs
Whole Family Services
Resettlement Programs
Immigrant Services
English Language/Citizenship Classes
Employment Services
Food Distribution
Groups (Adults)
Groups (Teens)
Other(s)
Please specify other services requested.
Maine Immigrant & Refugee Services
| 256 Bartlett Street | Lewiston, ME 04240
