Referrals to Crossroads | Addiction & Mental Health Treatment

If your client has consented to a referral, you may call us at 877.978.1667 or use the form below. While your email transmission will be encrypted in an effort to protect the confidentiality and security of the information provided, we recommend that you contact us by phone whenever you are communicating more detailed personal information.

"*" indicates required fields

Are You Inquiring About Residential or Outpatient Treatment?*

Residential

Outpatient

Greater Portland Counseling Center
71 US Route One, Suite E
Scarborough, ME 04074
P: 877-978-1667
F: 207-879-5576

Residential Programs Intake
71 US Route One, Suite E
Scarborough, ME 04074
P: 877-978-1667
F: 207-879-5576

Your Phone Number*

Your Email Address*

Referred By*

Referral Phone Number*

Client Name*

Client's Phone Number*

Client's Date of Birth*

Client's Insurance Provider*

Insurance Provider's Phone Number*

Reason for Visit

You deserve a second chance. Contact Crossroads today!

877.978.1667

877.978.1667

Make an Appointment