Maine DHHS - Questionnaire - Behavioral Health Homes (BHH)


Status: Incomplete
   

Behavioral Health Homes (BHH)


1. Date Case Worker assigned:

Date:



2. Date seen face to face:

Date:



3. Date of referral:

Date:



4. What tool was completed?

(Please select one.)


5. What covered services have been provided during the last review period?









6. Does the member receive Vocational Rehabilitation Services?

(Please select one.)


7. Does the member currently have a rent subsidy or live in subsidized housing?

(Please select one.)


Adult Service Only



Disclaimers (please check to confirm acceptance):