Step-by-step instructions for completing the 65 HCT referral form:
1. In the first section (titled "Type of Service Requested"), please check the box indicating the type of service to which you would like to refer:
65/HCT (Home and Community Treatment);
FFT (Functional Family Therapy – This is not offered at KBH, although is offered through other agencies if desired);
MST (Multi-Systemic Treatment); or
MST–PSB (Multi-Systemic Therapy for Problem Sexual Behavior)
If you are unsure whether the child being referred meets MST or MST-PSB eligibility, please see the “MST Screening Form”, which can be found in the “documents” section of Kennebec Behavioral Health’s website ().
2. In the second section (titled "Contact Information"), provide the information requested for whoever is requesting the service. This can be the parent/guardian, or it can be a provider. At the bottom of this section is a question asking if services are already being provided in the child's home. This refers to “home-based” services (i.e. HCT, FFT, MST, MST-PSB). The answer should be "no". Only one in-home provider can work with a family at a time.
3. In the third and fourth sections, please provide the child's demographics and current residence of child (address where in-home services will take place). MaineCare number is required.
4. Also provide child's/caregiver's primary language if not English. If the primary language is not English, indicate whether or not an interpreter service is utilized by the family (if so, please provide contact information).
5. In the next section, indicate who has legal guardianship/custody of the child and provide contact information.
6. Provide child’s diagnosis. Check the box indicating whether a MR/Autism diagnosis, a mental health diagnosis, or a developmental disability is the primary concern.
7. Next, provide the reason for the referral to this intensive, home/community based, family focused service, including information about how long and how problematic the current concerns are.
8. In the “Treatment History” section, indicate what other mental health/counseling services have been involved with the child and/or family (including dates of service and reason for services ending).
9. In the next session, if home-based services have worked with the family within the past six months, indicate any barriers to the past home-based service involvement leading to lasting changes and whether there are new circumstances that would suggest that another episode of home-based service is warranted.
10. In this section, describe what outcome is desired from the requested service and how long it is estimated that it would take to reach this goal.
11. The current legal guardian (usually, but not always the parent) then needs to initial the lines 1 - 4, and sign on the signature line.
** Important **: Without the initials and signature, the referral request cannot be processed.
The form is then sent to the provider (agency) of your choice. To refer to Kennebec Behavioral Health, please direct the referral form or any questions to:
For HCT: For MST & MST-PSB:
David Whitestone, Ph.D. Melissa Winchester, LCPC
Director, Family Behavioral Health & Visitation Service Director, MST Services
Kennebec Behavioral Health Kennebec Behavioral Health
66 Stone Street 66 Stone Street
Augusta, ME 04330 Augusta, ME 04330
(207) 626-3455 (207) 626-3455
Fax: 629-9083 Fax: 629-9083
The most current version of the referral form (and other information related to the general home-based, family intervention programs) can also be found at: