Brighter Futures Inc. - Dedicated To Keeping Families Together
Brighter Futures Inc.
1349 Kempsville Road #202
Virginia Beach, VA 23464
Office: (757) 216-8350
Fax: (757) 216-8351
Referral §645.C
Point of Contact:   Office     Phone      Field       Other
Prospective Patient Name:
Age:                               DOB:                                           Gender:  Male or Female
Social Security # :             
Insurance Information:
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.
Patient is:
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:
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