Adult Residential Services

Therapeutic Foster Care

Clinical

Adult Residential Services

Brighter Heights Arizona delivers Behavioral Health Residential Facility (BHRF) treatment services to adults with a quality diagnoses of Severe Mental Illness (SMI). Patients enrolled in our program receive individualized, trauma-informed services provided by our medical, clinical, nursing and paraprofessional staff in less restrictive treatment settings.

PATIENT PROFILE

Must have obtained a qualifying SMI diagnosis
Needs served: Schizophrenia Spectrum disorders; TBI related behavioral challenges; assisted medication administration needs; other SMI qualifying diagnoses
May experience challenges with interpersonal relationships, coping, low impulse control or experience of trauma
Expresses an interest in a supportive environment for maintenance of sobriety
May have experienced suicidal ideations (SI) and self-injurious behaviors (SIB) .

Brighter Heights Arizona Program Application Form

BHRF (Behavioral Health Residential Facility/TGH) (SMI Adults Only)

Completed by:

Date:

Name: [text* -full-name]

Date of Birth:

Ethnicity:

SSN:

Gender:

Is client COT:

Primary Language:

Will an interpreter be needed? If so, for what language and for whom?:

Insurance (Please Include all):

Who is the Funder/Payer?

List ALL current behavioral health diagnoses (with the correct ICD-10 codes), starting with the Primary Diagnosis:

List ALL physical/medical concerns/diagnoses (Ex. Prev. surgeries, broken bones, hx of seizures, diabetes, etc.) (Medical accommodations; C-PAP, wheelchairs, incontinence, dialysis, etc.)

All Allergies: Medication and Non-Medication

CURRENT PHYSICAL LOCATION of the client

Name of the facility/home:

Physical Address of the client:

Contact Person:

Phone and Email:

REFERRING AGENCY/HEALTH HOME

Agency Name:

Contact Name:

Address:

Phone:

Email:

LEGAL GUARDIAN

Name:

Relation:

Type of Guardianship:

Address:

Phone:

Email:

PROBATION

Name:

County:

Address:

Phone:

Email:

OTHER/ADVOCATE

Agency Name:

Job Title:

Address:

Phone:

Email:

SUMMARY

Summarize client’s placement history for the last year:

Why does client need to leave their current placement?

What is the current discharge plan once the client is ready to leave us?

Are there any legal issues? (What has the client been charged with, the dates, and the outcome?)

Is the client on probation and if so, why?

Are there any medical reasons that the client would not be able to receive any physical intervention? If yes, please explain in detail.

Does the client currently have lice, bed bugs, or fleas?

Please list the client’s positive attributes/goals?

RISK HISTORY (In DETAIL) any history of the following that apply (including dates):

Fire Setting:

Cruelty to Animals:

Suicide/ Danger to self-behaviors/attempts:

Homicide/ Danger to others- behaviors/attempts:

Substance Abuse: (What substance(s) and when is the last day of known substance abuse?)

Physical Abuse/Domestic Violence:

Sexual Maladaptive Behaviors (Is the client a Registered SO):

Sexualized Behaviors (Exploitation, hyper-sexualized, poor boundaries with others)

Hallucinations/Delusions:

Any Other Additional Risks not mentioned above:

Please provide the most recent version of the following documentation (if you haven’t already):

Most recent/updated Referring agency assessment (required by AHCCCS)
Most recent/updated Service plan/Treatment plan (required by AHCCCS)
Funder’s prior auth for treatment (required by AHCCCS)
ART staffing notes for past 2-3 months minimum
ADHS Assessment (Arizona Department of Health Services)
Most recent psych evaluation (within the past year)
Court Order Documents
Current Legal Guardianship Paperwork
Therapy notes (3-6 months minimum)
Incident reports (3-6 months minimum)
Substance Abuse Treatment history
Physical (within last 30 days)
TB test results (within the last year)
Negative COVID test
Medical history (including med list)

All TRBHA referrals MUST include the following in order to get approved by AHCCCS:

Current Treatment Plan (no more than 30 days old) – (must include set of goals for client to complete and state what level of care is being recommended)
Current Behavioral Health Agency Psychiatric Assessment (dated within the last year)

Click the Link Below for Additional Information or

Make A Referral

2517 N Great Western Dr, Suite P
Prescott Valley, AZ 86314

928-772-4131 X 1009
928-227-4589

Admissions.az@vivantbh.com

Compliance Hotline

1.855.955.3070 (toll-free)
compliance@bh-arizona.com

Notice of Privacy Practices
Aviso de Prácticas e Privacidad en Español