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Referral Form
uhs@RBHSA
2026-06-23T17:05:11+00:00
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Referral Form
Referral Form with File Upload
Treatment Program Interested in:
Children & Adolescent Programs
Acute Psychiatric Inpatient Program (Male and Females ages 4-17)
Adolescent Male Extended Care Unit (Males 12-17)
Adolescent Sub-Acute Program (Male & Female 12-17)
Adult Inpatient Programs
Adult Acute Psychiatric Inpatient Program
Adult Inpatient Dual-Diagnosis/Co-Occurring Mental Health & Substance Use Treatment program
Adult Outpatient Programs
Adult Partial Hospitalization Program (PHP) M-F 9:00 AM-2:30 PM
Adult Intensive Outpatient Program (IOP) M-Sat. 9:00 AM-12 PM
Adult Intensive Outpatient Program (IOP Nights) M-F 6:00PM-9:00P PM (Program opening soon)
Interested in Virtual (if approved by insurance)
Demographics
Patient Name
First
Middle
Last
Height
Weight
Birthdate
Age
Birth Sex
Preferred Name
Preferred Pronouns
Patient Cell Phone (Guardian cell phone if minor)
Patient Email (Guardian email if minor)
Patient SSN
Insurance
Insurance Policy Number
Guardian's Name
First
Last
Relationship to Patient
Cell Phone:
Home Phone:
Work Phone:
Professional referral source
I am a professional referral source filling this form on behalf of a patient
How did you learn about us?
How did you learn about us?
Current Therapist/Outpatient Provider
Physician/Nurse/Therapist
School
Hospital
Social Media
Website/Google
Family/Friend
Other
Provider Name
Agency/Clinic/Practice Name
School Name
Hospital Name
Staff Member Name
Which social media?
Facebook
Instagram
LinkedIn
How did you learn about us?
Reason For Referral
Untitled
Depression
Anxiety
Mood Changes
Behavioral Concerns
Substance Use
Suicidal Thoughts/Safety Concerns
Trauma/PTSD
Psychosis/Hallucinations (Believing things that aren't true/seeing or hearing things others can't see or hear)
Eating disorder concerns
School Academic Concerns
Family/Relationship Concerns
Other
Please provide additional details regarding current concerns/symptoms
How would you prefer to complete the level of care assessment?
In Person
Virtual (telehealth) visit
Phone
No Preference
Best contact phone number, if different than above
Additional Information
Notes
Supporting documents
Drop files here or
Select files
Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 15.
Upload any supporting documents that may assist with the referral/assessment process such as: Medication list, Insurance Card, Recent discharge Paperwork, School documents/IEP, Current Treatment Records, Psychological testing/evaluation, Therapy or psychiatric records, Letter of Recommendation-If for Sub-Acute program Medication list Insurance Card Recent discharge Paperwork School documents/IEP Current Treatment Records Psychological testing/evaluation Therapy or psychiatric records Letter of Recommendation-If for Sub-Acute program
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