Riverview Behavioral Health School Referral Form
Counseling Program: 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.
(877) 870-8745 TEXARKANA SITE
http://www.riverviewbehavioralhealth.com/about/contact
REFERRAL FORM:
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