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Connect with our team any time by calling our office, or fill out the secure form below and we’ll get in touch right away. We can quickly verify your insurance so that you or your loved one can begin treatment confident that our services are covered. Outpatient mental health treatment programs are typically covered by insurance

First Name

Last Name

Date Of Birth

Email address

Callback phone number*

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Preferred type of appointment*

In-person Telemedicine

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How will you be paying for services?*

Health Insurance Self-pay

If you selected Health Insurance, please provide the details below. If you are self-pay, please ignore the below and proceed to submit the inquiry. Thank you

Policy Holder's First Name*

Policy Holder's Last Name*

Policy Holder's Date Of Birth

Policy Holder's Address*

Street Address Line

City

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Zip Code

Insurance Company's Name*

Insurance Company's Phone Number*

Member ID*

Group Number*

Subscriber relationship to client*

Privacy & Confidentiality Notice: In the state of Maine, minors may consent to outpatient mental health treatment, which includes rights to privacy and confidentiality regarding their care (22 M.R.S. § 1502 and 22 M.R.S. §1711-C). Parents and guardians are welcome to complete this form on behalf of their child. However, The Family Center of Maine cannot confirm treatment status or provide information regarding a client age 14 or older without written consent from the client.

New Patient Inquiry

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