BHRP - Treatment Verification Form 041315
State of Connecticut Department of Mental Health and Addiction Services
Behavioral Health Recovery Program (BHRP) - Basic
Administrative Services Organization: Advanced Behavioral Health, Inc. P.O. Box 735, Middletown, CT 06457
PHONE: 1-800-658-4472 FAX: 1-866-249-8766
TREATMENT VERIFICATION FORM
DATE:
RE:
Request for BHRP - Basic
Applicant's Name:
_________________________________________
Treatment Provider:
_________________________________________
Provider Address:
_________________________________________
Level of Care / Type of Treatment: _________________________________________
Treatment Start Date: ______________ Expected Discharge Date: ______________
Participation in behavioral health treatment is a requirement for individuals to access services through the DMHAS Behavioral Health Recovery Program (BHRP) ? Basic. By signing below, I am attesting that this individual is participating in behavioral health treatment.
________________________________________________________________________________
Name
Agency
Contact Number
_________________________________________________________ Signature
_______/_____/____ Date
This form can be completed by Recovery Support Services staff for individuals who have an intake scheduled, ONLY for the first month. Once individuals have begun attending treatment, this form should be completed by a clinician at the Treatment Provider.
Please fax the completed form to ABH at 1-866-249-8766
If there are any questions contact BHRP ? Basic staff at 1-800-658-4472.
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