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Online Therapy and Counseling

Discover comprehensive information on the best virtual couples therapy. Learn about virtual therapy for couples, online couples therapy, and couples online therapy approaches. Enhance relationship dynamics with expert guidance and strategies.

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YOUNG PRP (Age 5-17)

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REFERRING THERAPIST INFORMATION

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

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Adult PRP

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Date Of Referral *

Date of Birth *

Sex at Birth *

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City *

Address 2

Contact Number *

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REFERRING THERAPIST INFORMATION

Name and Credentials of Therapist *

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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? *

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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 *

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Is the Participant Receiving Fully Funded DDA Benefits? *

Has Medication Been Prescribed to Support Mental Health? *

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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? *

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