Kennebec County Diversion Program Community Referral Form

The form is intended to provide a pathway for members of the public to provide information to our Kennebec County Diversion Care Coordinator for follow up or outreach to a person struggling with Substance Use Disorder (SUD). The our Diversion Care Coordinator l will contact the person making the referral for supplemental information as needed prior to making contact with the person they would like to connect to support.

Please complete this form with as much information as you have available when making a referral to the Kennebec County Diversion Program.

Referral Information

Legal Name(Required)
MM slash DD slash YYYY
Mailing Address

Your Information

Your Name(Required)