Riverview Behavioral Health School Referral Form
http://www.riverviewbehavioralhealth.com/
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
http://www.riverviewbehavioralhealth.com/about/contact
EXAMPLE OF SCHOOL BASED SERVICES REFERRAL FORM:
SCHOOL BASED SERVICES
REFERRAL FORM
Date: __________________
Student’s Name: ______________________ SSN: ________________
DOB: __________________ Age: ___________
School: ____________________________________ Grade: ________
Referred By: _______________________________________________
Presenting Problems:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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
Ph: (870)777-4989
Fax: (870)777-4783
RIVERVIEW BEHAVIORAL HEALTH SCHOOL BASED SERVICES REFERRAL FORM