Client Referral Form

This secure form is for initial inquiries only. Submission does not guarantee an appointment or establish a treatment relationship. Do not use this form for emergencies; call or text 988 or call 911.

Are you a Maine Resident? Only Maine residents are currently accepted to this practice.

Do you have Blue Cross/Blue Shield/Anthem Shield Insurance (Only current Insurance Accepted)?

Clinician Choice

Brian Selby, Ph.D. Christine L.B. Selby, Ph.D.

First name

Last name

Date of birth

Full name

Relationship to client

Phone number

Email address

Address

Full name

Phone number

Email address

Role or relationship to client

Practice or organization name

Reason for referral

Tell us what the client is looking for, and what you'd like us to help with.

Additional comments

Your information will be encrypted.