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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

Email Us

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

 

 

 

 

 

REFERRAL FORM:

 

 

 

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

 

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