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Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

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PRP Referrals
Special Program Event

YOUNG PRP (Age 5-17)

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Your Email

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 *

Email

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 *

Email

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. *

Yes
No

ICD-10-INFORMATION

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Primary Diagnosis *

Has the Participant been Active in Treatment? *

Yes
No

Additional Diagnosis

Has Medication been Prescribed to Support Mental Health? *

Yes
No

RISK ASSESSMENT

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

Yes
No

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

Yes
No

Is the Participant Currently Enrolled in Targeted Case Management? *

Yes
No

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

Yes
No

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

Yes
No

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)

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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Full Name *

Email *

Phone No *

Location

Message *

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YOUNG PRP (Age 5-17)

Please enable JavaScript in your browser to complete this form.

Layout

Your Email

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 *

Email

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

Layout

Supervisor Name

Agency Name *

Fax Number

Supervisor Credentials

Phone Number *

Email

CLINICAL INFORMATION

Layout

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. *

Yes
No

ICD-10-INFORMATION

Layout

Primary Diagnosis *

Has the Participant been Active in Treatment? *

Yes
No

Additional Diagnosis

Has Medication been Prescribed to Support Mental Health? *

Yes
No

RISK ASSESSMENT

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

Yes
No

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

Yes
No

Is the Participant Currently Enrolled in Targeted Case Management? *

Yes
No

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

Yes
No

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

Yes
No

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

Agree

Layout

Signature *

Date

Credentials *

Supervisor

Layout

Provide Supervisor's Name (If Applicable)

Mental Health Professional Signature

Provide Supervisor's Credentials (If Applicable)

Adult PRP

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Layout

Your Email

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 *

Email

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

Layout

Supervisor Name

Agency Name *

Fax Number

Supervisor Credentials

Phone Number *

Email

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. *

Yes
No

ICD-10-INFORMATION

Please Select Primary Diagnosis *

Additional Diagnosis

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Is the Participant Receiving Fully Funded DDA Benefits? *

Yes
No

Has Medication Been Prescribed to Support Mental Health? *

Yes
No

Has the Participant been Active in Treatment? *

Yes
No

RISK ASSESSMENT

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

Yes
No

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

Yes
No

Is the Participant Currently Enrolled in Targeted Case Management? *

Yes
No

PRP Services/Referral has been Explained to Participant? *

Yes
No

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

Yes
No

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

Layout

Provide Supervisor's Name (If Applicable)

Mental Health Professional Signature

Provide Supervisor's Credentials (If Applicable)

Please enable JavaScript in your browser to complete this form.

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Full Name *

Phone No *

Email *

Message