9 Green Street,

Augusta, ME 04330

400 Commercial Street,

Portland, ME 04101

Contact and Referral Information

Phone: (207)777-3399

Fax: (207)777-3391

Blue Willow Counseling Locations

Blue Willow Counseling

Executive Director: Jennifer Wood, LCSW, CCS, LADC




101 East Avenue,

Lewiston, Maine 04240

​EZ-Referral Form

                                             Please complete and fax to 777-3391
                                              BLUE WILLOW EZ-REFERRAL FORM

Date: ___________________

Name:_________________________________________________________________________


D.O.B: ____________________________ SS#: ______________________________________


Mailing Address:____________________________________________________________________


Home Phone: _____________________________     Ok to leave a message:        YES             NO

Cell Phone:     _____________________________    Ok to leave a message:        YES             NO


How did you hear about us?__________________________________________________________


Referred By: __________________________________________ Phone: __________________

Client Seeking:  
Mental Health ____ Treatment  ____ D.E.E.P. (treatment, evaluation) ____ Case Management      

Substance Abuse    ____ Evaluation/Assessment      ____ Intensive Outpatient


Date of Last Physical Exam: _________


Presenting Psychosocial Concerns: ______________________________________________________________________________
______________________________________________________________________________

Insurance:           


Mainecare: ID# ______________________         Self-Pay 

​Other: ID# ______________________