COMMUNITY CONNECTIONS
A STATEWIDE RECREATIONAL
LINKAGE SERVICE
Website: www.mmhc.us
Office 941-2998
Fax- 941-2996
APPLICATION
FOR SERVICES
NAME:_______________________________________________________________
MAILING
ADDRESS:_____________________________________________________
CITY:
COUNTY______________ TELEPHONE: _____________ DATE OF BIRTH:___________
RELEASE OF INFORMATION
I authorize the Mental
Health Service Provider named below to release the information requested below
to be used for verification of eligibility for Community Connections, a program
providing recreation linkage services to Mental Health Consumers. This
information may be available to Community Connections, a program of Maine
Mental Health Connections, Inc. I further authorize the Mental Health Service Provider
named below to release information pertaining to membership in Community
Connections including information and materials regarding usage of program
facilities and appropriateness of usage of the program. I have had explained to me the risks and
benefits of releasing the requested information and understand that I may
revoke my consent at any time.
This release will expire one year from today.
Signature of Client or Guardian_____________________________________
Date______________
Person requesting information: Program
Manager and staff of Community Connections
VERIFICATION BY MENTAL HEALTH
SERVICE PROVIDER
(Applicant: Please have your Medical Mental Health Service Provider complete this section
Before Returning this Application to C.C.)
The above named person is a
recipient of Maine Mental Health Services.
Persons who are receiving Services Strictly
For Substance Abuse, Mental
Retardation, Learning Disabilities, and Head Trauma are Not Eligible on their own. Please provide at least One other Mental Health
diagnosis.
______________________________________________
____________________________________________
Medical Provider (Print
Name) Provider
Title (Print)
_____________________________________________________ _____________________________________
Medical Provider
Signature Date
____________________________________________________________________________________________
Name
of Provider Health Care (Please Print)
____________________________________________________________________________________
Address
of Providing Health Care (Please
Print)
Diagnostic
Criteria
Principal Diagnosis: ____________________________________________________
This Section is Optional. Funding sources request collection of the
following information. It is also useful
to the program to better serve the
participants. Your answers are
confidential and will not affect your eligibility.
Age:_______________________ Sex: o Male
o Female
Educational
Background: Highest
Level Completed: _______________________
Racial/Ethnic:
o
White
o African-American o
Hispanic
oAmerican
Indian/Alaskan Native o
Asian/Pacific Islands o Other
Marital
Status:
o
Never Married o
Married oRemarried
o
Separated o Divorced o Widowed
Income Level:
o
Less than $5,000 o
$5,000 - $6,999 o $7,000 - $9,999
o
$10,000 - $14,999 o
$15,000 - $19,999 o $20,000 - $24,999
o
$25,000 - $34,999 o
More than $35,000
Living
Arrangements:
oAlone o
With Other o
Boarding Home o
Supported Living
o
Nursing Home o
Criminal Justice o
Crisis Arrangements o
Homeless
o
Other Protective Living Arrangement
Referral
Source:
o
Friend oTogether Place
Social Club o Newspaper
o
Clergy o Mental Health
Provider o Physical Health Provider
o
Criminal Justice Sector o
Inpatient Psychiatrist
o Residential
o
o Substance Abuse Sector o School
o Other (Please
Specify)_______________________________________________________________
Prior
Treatment History:
Inpatient Treatment o
Yes o
No
Community Mental Health Treatment o
Yes o
No
Prior Substance Abuse Treatment o
Yes o
No
Physical Disability:
o
Deaf
o
Learning
o
None
o
Other
o
Mental Retardation/Developmentally Disabled
o Mobility Impaired
o Emotionally/Developmentally Delayed
o Blind
Revised
03/2011