SOUTHERN KENNEBEC CHILD DEVELOPMENT CORPORATION
337 Maine Avenue, Farmingdale, ME 04344
Tel: (207) 582-3110 ♦ Fax: (207) 582-3112 ♦ TF: (800) 525-2229 ♦ www.skcdc.org
REFERRAL CHECKLIST
Mental Health Services
* Please be sure that all of the necessary information and releases are complete and included.
Early Head Start
Individual Child Observation (Mark Rains)
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Mental Health Consultant Request form
SKCDC Standard Release Consent for the Release/Request of Confidential Information
Consent for Observation and Assessment/Evaluation
Overall Classroom Observation (David Whitestone)
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Mental Health Consultant Request form
Kennebec Behavioral Health Request for Services
3-5 Year Olds Head Start / Child Care
MaineGeneral Medical Center (Michael Apolito)
* (Serious behavior only concerns)
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Mental Health Consultant Request form
SKCDC Standard Release Consent for the Release/Request of Confidential Information
Consent for Observation and Assessment/Evaluation
MaineGeneral Medical Center (Dick Watson)
(Full mental health consultation, technical assistance to classroom, individual child observation, meeting with
parent/guardian only)
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Mental Health Consultant Request form
SKCDC Standard Release Consent for the Release/Request of Confidential Information
Consent for Observation and Assessment/Evaluation (if individual child is involved)
Kennebec Behavioral Health (David Whitestone/Sarah Charland)
(Individual child and/or overall classroom observations)
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Mental Health Consultant Request form
Kennebec Behavioral Health Request for Services
SKCDC Standard Release Consent for the Release/Request of Confidential Information
Consent for Observation and Assessment/Evaluation (if individual child is involved)
In Home Support Only for Families
Kennebec Behavioral Health
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106749121
DHHS Referral for MaineCare (Section 65 HCT)
SKCDC Standard Release Consent for the Release/Request of Confidential Information
Revised: 10/03/2011