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Caregiver's Retreat Application
Maine Caregiver Contact Information
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country


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Further Info

*Attendance at the retreat is not a substitute for any counseling or treatment in which you may be involved. CONFIDENTIALITY STATEMENT: Consumer confidentiality is governed by many laws and regulations. These include: HIPAA (regulations at 45 CFR Parts 160 and 164), the federal law related to privacy of health information; Federal substance abuse law (regulations at 42 CFR Part 2); State mental health confidentiality law (34-B M.R.S.A. § 1207) and Community Service Network law (34-B M.R.S.A. § 3608); Federal protection and advocacy agency regulations (42 CFR Part 51); and State mental health confidentiality regulations (Rights of Recipients of Mental Health Services, Part A(IX) Rules Governing the Disclosure of Information Pertaining to Mentally Disabled Clients). If there is a clear and substantial reason to believe that a consumer poses an immediate danger of serious physical harm to him/herself or others, providers must notify any person (including law enforcement and the endangered person) who may reasonably be able to prevent or lessen the threat.