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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

Email Us

http://www.riverviewbehavioralhealth.com/about/contact

 

 

 

 

 

EXAMPLE OF SCHOOL BASED SERVICES REFERRAL FORM:

 

 

 

http://www.riverviewbehavioralhealth.com/wp-content/uploads/sites/12/2013/12/logo.png

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