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Provider Referral Form

Request Our Services Form

Email us below, or call anytime Monday through Friday, from 7:00am to 4:00pm. Call toll-free (800) 781-0070.

We're here to help.

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Person Completing This Form

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Individual Needing Service

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Date of Birth
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Does this person have a legal guardian or other court appointed representative?
Does this person have a legal guardian or other court appointed representative?
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Does the person needing services require an interpreter?
Does the person needing services require an interpreter?
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I prefer to be contacted by
I prefer to be contacted by
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Services Needed

What service(s) are you requesting?
What service(s) are you requesting?
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What type of insurance do you have?
What type of insurance do you have?
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Assistance Plus is a social service and non-medical agency with offices in Benton, Waterville and Wilton, Maine. We provide long term home care, developmental disabilities, and behavioral health services.

 

Our Mission:

   By supporting and caring for people at all points in life, together we can make a difference.

Our Vision:

    Maine ~ where individuals in need receive services that support choices for a quality life.

Our Values:

   Commitment ~ Integrity ~ Compassion

 

Proud Member MACSP 2018 300x153    Member Alliance    mcoa small 211x300   HIPAA Verified Seal HR Email Signature

CONTACT US


1-800-781-0070
 PO Box 358
Fairfield, Maine 04937
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