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Awareness Program

World Suicide Prevention Day – Connection Between OCD and Suicide

Leave a Comment / Awareness Program / Emma Johnson

On September 10, designated as World Suicide Prevention Day, people all over the world discover more about suicide. This date […]

World Suicide Prevention Day – Connection Between OCD and Suicide Read More »

how technology effect on mental health - postive and negtive effect effects on mental health

The Effects of Technology on Mental Health

Leave a Comment / Awareness Program / John Wick

Technology has changed how we work, interact, and access information. Billion people use social media, and the average individual spends

The Effects of Technology on Mental Health Read More »

The Vital Importance of Mental Health Awareness

Leave a Comment / Awareness Program / John Wick

Mental health understanding is one of the factors that you can not ignore, as it is rising in the modern

The Vital Importance of Mental Health Awareness Read More »

National Mental Health Awareness Month

Leave a Comment / Awareness Program / John Wick

May is National mental health awareness month. Starting in 1949, Mental Health Awareness Month worked as a beacon in the

National Mental Health Awareness Month Read More »

Exploring the Advanced Center for Psychotherapy

Leave a Comment / Awareness Program / admin

Psychotherapy is a collaborative, customized treatment. It is based on the idea that studying our ideas, feelings, and behaviors can

Exploring the Advanced Center for Psychotherapy Read More »

Suicide Awareness

Leave a Comment / Awareness Program / John Wick

By the time an individual is faced with the urge to commit suicide, there are so many other different underlying

Suicide Awareness Read More »

National Suicide Awareness Day

Leave a Comment / Awareness Program / admin

World Suicide Prevention Day is celebrated all over the world every year on September 10th. It serves as a somber

National Suicide Awareness Day Read More »

Welcome to BrightPoint Wellness, your trusted destination for professional mental health counseling services. Our team of experienced counselors is committed to giving you the help and direction you need to deal with life’s difficulties.

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YOUNG PRP (Age 5-17)

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Participant Name *

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Zip Code *

Home Address *

Medicaid Number *

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Parent/Guardian Name (If Applicable)

Please Select Jurisdiction/County *

Date Of Referral *

Date of Birth *

Sex at Birth *

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City *

Address 2

Contact Number *

Gender Identity and Preferred Pronouns, Please Select *

REFERRING THERAPIST INFORMATION

Name and Credentials of Therapist *

If LMSW or LPGC, Please Provide Name and Credentials of Supervisor

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Supervisor Name

Agency Name *

Fax Number

Supervisor Credentials

Phone Number *

CLINICAL INFORMATION

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Reason for Referrel *

Participant's Strength and Current Resources *

Goals of Requested Services *

Has a Mental Health Assessment and Treatment Plan been Completed? If yes, a Copy will need to be Provided if Accepted into the Program. *

ICD-10-INFORMATION

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Primary Diagnosis *

Has the Participant been Active in Treatment? *

Additional Diagnosis

Has Medication been Prescribed to Support Mental Health? *

RISK ASSESSMENT

Are there any Risks for Aggressive Behavior, Suicide, or Homicide? *

Is the Participant Coming out of In-Patient or at Risk of Going into In-Patient? *

Is the Participant Currently Enrolled in Targeted Case Management? *

PRP Services/Referral has been Explained to Participant or Parent/Guardian of Participant? *

Is the Participant Currently Enrolled/Authorized for Another PRP? *

By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature *

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Signature *

Date

Credentials *

Supervisor

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Provide Supervisor's Name (If Applicable)

Mental Health Professional Signature

Provide Supervisor's Credentials (If Applicable)

Adult PRP

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Participant Name *

Age *

Select Race *

Zip Code *

Home Address *

Medicaid Number *

Please Select State *

Parent/Guardian Name (If Applicable)

Please Select Jurisdiction/County *

Date Of Referral *

Date of Birth *

Sex at Birth *

Please Select *

City *

Address 2

Contact Number *

Gender Identity and Preferred Pronouns, Please Select *

REFERRING THERAPIST INFORMATION

Name and Credentials of Therapist *

If LMSW or LPGC, Please Provide Name and Credentials of Supervisor

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Supervisor Name

Agency Name *

Fax Number

Supervisor Credentials

Phone Number *

CLINICAL INFORMATION

Reason for Referrel *

FUNCTIONAL IMPAIRMENTS

Please check all that apply and describe at least 3 Specific Mental Health Symptoms related to The Participant's Priority Population Diagnosis and describe how they Impact the Functional Impairments Below

Does the Participant Have a Marked Inability to Establish or Maintain Competitive Employment? *

Does the Participant Have a Marked Inability to Perform Instrumental Activities of Daily Living (e.g., Shopping, Meal Preparation, Laundry, Basic Housekeeping, Medication Management, Transportation, and Money Management)? *

Does the Participant Have a Marked Inability to Establish/Maintain a Personal Support System? *

Does the Participant Have Deficiencies of Concentration/Persistence/Pace Leading to Failure to Complete Tasks? *

Is the Participant Unable to Perform Self-Care (Hygiene, Grooming, Nutrition, Medical Care, Safety)? *

Does the Participant Have Marked Deficiencies in Self-Direction, Shown by Inability to Plan, Initiate, Organize, and Carry Out Goal-Directed Activities? *

Does the Participant Have a Marked Inability to Procure Financial Assistance to Support Community Living? *

OTHER

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Participant's Strength and Current Resources *

What is your Goals of Requested Services *

Has a Mental Health Assessment and Treatment Plan Been Completed? If Yes, a Copy Will Need to Be Provided If Accepted into the Program. *

ICD-10-INFORMATION

Please Select Primary Diagnosis *

Additional Diagnosis

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Is the Participant Receiving Fully Funded DDA Benefits? *

Has Medication Been Prescribed to Support Mental Health? *

Has the Participant been Active in Treatment? *

RISK ASSESSMENT

Are there any Risks for Aggressive Behavior, Suicide, or Homicide? *

Is the Participant Coming out of In-Patient or at Risk of Going into In-Patient? *

Is the Participant Currently Enrolled in Targeted Case Management? *

PRP Services/Referral has been Explained to Participant? *

Is the Participant Currently Enrolled/Authorized for Another PRP? *

By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature *

Agree

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Signature *

Date

Credentials *

Supervisor

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Provide Supervisor's Name (If Applicable)

Mental Health Professional Signature

Provide Supervisor's Credentials (If Applicable)

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Full Name *

Phone No *

Email *

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