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UHS-NVT

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100 Rivendell Drive
Benton, AR 72019

Toll-Free Phone:
800-264-5640
Local Phone:
501-316-1255

© Rivendell Behavioral HealthServices of Arkansas. All rights reserved.

Physicians are on the medical staff of Rivendell Behavioral Health Services of Arkansas, but, with limited exceptions, are independent practitioners who are not employees or agents of Rivendell Behavioral Health Services of Arkansas. The facility shall not be liable for actions or treatments provided by physicians. Model representations of real patients are shown. TRICARE® is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. ATransportation options may be available – please contact us to learn more.

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Referral Form

Comments

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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

Is user a professional?

I am a professional referral source filling this form on behalf of a patient

Referral Source/Physician/Therapist

Referring Provider's Name

First Last

Agency/Clinic/Practice Name

Agency/Clinic/Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone

Office Phone

Fax

Email

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

Check all that apply

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

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

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 15.

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