School-Based Counseling Program
School based counseling services are designed for students who have learning difficulties, or for those that may find it difficult to maintain appropriate behavior while attending classes. Case managers and licensed counselors are available to see children and adolescents in the school setting during the school day.
(877) 870-8745 TEXARKANA SITE
EXAMPLE OF SCHOOL BASED SERVICES REFERRAL FORM:
SCHOOL BASED SERVICES
Student’s Name: ______________________ SSN: ________________
DOB: __________________ Age: ___________
School: ____________________________________ Grade: ________
Referred By: _______________________________________________
Legal Guardian Name: _________________ Relationship: __________
Phone Number: ____________ Alternate Phone Number: __________
Name of Insurance: ________________ Insurance Number: _________
By signing this form I authorize the Release of Information to Riverview Behavioral Health.
Parent/Guardian Signature Date
225 S. Main St.
Hope, AR 71801