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Brighter Futures Inc.
1349 Kempsville Road #202
Virginia Beach, VA 23464
Office: (757) 216-8350
Fax: (757) 216-8351
Point of Contact: Office Phone Field Other
Prospective Patient Name:
Age: DOB: Gender: Male or Female
Social Security # :
Patient needs and concerns:
Individual must meet at least two of the following criteria on a continuing or intermittent basis:
Have difficulty in establishing or maintaining normal interpersonal relationships to such
a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with Family or Community.
Exhibit such inappropriate behavior that repeated interventions by the mental health, social
services or judicial systems are necessary.
Exhibit difficulty in cognitive ability such that they are unable to recognize significantly
inappropriate social behavior.
At risk of being moved into an out-of-home placement due to a documented medical need of
the Patient, or
Is being transitioned to home from out-of-home placement due to a documented medical need
of the Patient.
Name, Address & Phone # of referral source:
Outcome of Screening Process:
____ Accepted QMHP-C Assigned:
____ Referred Reason & Referred to: