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Psychiatric services

Emergency Psychiatric Services: A Lifeline in Times of Crisis

Leave a Comment / Psychiatric services / malik faraz

In today’s world, people are busy, and depression does not wait. Therefore, depression cases are on the rise. According to […]

Emergency Psychiatric Services: A Lifeline in Times of Crisis 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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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 *

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 *

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)

Adult PRP

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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 *

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 *

Message

Psychiatric services

Emergency Psychiatric Services: A Lifeline in Times of Crisis

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YOUNG PRP (Age 5-17)

REFERRING THERAPIST INFORMATION

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

CLINICAL INFORMATION

ICD-10-INFORMATION

RISK ASSESSMENT

Supervisor

Adult PRP

REFERRING THERAPIST INFORMATION

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

CLINICAL INFORMATION

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

OTHER

ICD-10-INFORMATION

Additional Diagnosis

RISK ASSESSMENT

Supervisor