top of page

Home
About
- Resources
Services
Referrals
Client Portal
Careers
Contact
More

Use tab to navigate through the menu items.

Thank you for your interest in referring to Rae of Hope, LLC. This form allows individuals, families, providers, schools, and community partners to submit referrals for our behavioral health services. Please complete the information below so our team can review the referral and follow up regarding eligibility, next steps, and service availability.

Rae of Hope Referrals

Referral Type

Choose at least one:*

Children's Outpatient Therapy

Group Therapy

Adult Outpatient Therapy

Telehealth Sessions

Co-Parent Sessions

Target Case Managemet

Section 65 HCT

Section 28 RCS (Non Specialized)

Reason for Referral

Pick one or more*

Eating Disorder Treatment

Trauma/PTSD

Attachment/Relational

Anxiety/Depression

Parenting Support

ADHD Support

Other

Patient Information

First name*

Last name*

Date of Birth*

Month

Day

Year

Guardian Name*

Phone*

Email*

Address*

Who has custody of minor?*

Preferred Contact Method*

Phone

E-Mail

Text

Known Diagosis*

Current Services*

Referral Source

Referring Provider*

Relationship to Patient*

Organization/Practice*

Email*

Phone*

Fax

Reason for Referral/Goals for therapy*

Do you have a recent evaluation?*

Insurance Information (if applicable)

Insurance Provider

Policy Holder Name

Member ID

Date of Birth of Policy Holder

Month

Day

Year

File upload

OUR OFFICE

HOURS

INSURANCE ACCEPTED

FEES

Address: 284 Main Street

Suite 280

Wilton, ME 04294

Phone: 207-808-0432

Email:

Mon - Fri: 8am - 5pm

MaineCare

Aetna

Discounted/Sliding Fee Available

bottom of page