* Required Information
Client Name
*
Date of Birth
Age
Sex
Address
*
Home / Contact Phone
*
Parent Name and Address (if different from above)
Social Worker
Guardian
Other Legal
Insurance Company Name
Subscriber Name
Subscriber ID Number
Statement of Problem
Please attach any documentation/background information which may be helpful
Choose a file
Date of Inquiry
Person Completing Form
Brighter Possibilities Staff Only
Date Insurance Verified
CTSS Covered Under Insurance
Yes
No
Date of Last Diagnostic Assessment/Name of Provider
This client meets CTSS eligibility requirements and will be receiving CTSS services
Yes
No
School-Base Grant/Services
Yes
No
Home-Based program
Yes
No
Expected Start Date
Individual Therapist/Contact Information
