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      • Adolescent Male Extended Care Unit
      • Substance Abuse
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    • Overview
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    • Partnerships
  • Admissions
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    • Visiting Hours
    • What to Bring
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In case of a medical emergency, psychiatric crisis, or if you are at risk of harming yourself or others, CALL 911 or seek the nearest emergency room.

If you need to reach us immediately, call us at 800-264-5640.
Licensed mental health professionals are available 24 hours a day, 7 days a week to assist you or your loved one.

To schedule a level of care assessment or for more information, please call 800-264-5640 or use the form below. Walk-ins are welcome, and appointments can also be made. We respect your privacy and hold all information discussed in the strictest confidence.

This form is for general questions about Rivendell’s services, programs and admissions and IS MONITORED DURING NORMAL BUSINESS HOURS ONLY. If you are experiencing a medical emergency, DO NOT use this form.

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100 Rivendell Drive
Benton, AR 72019

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

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© 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

This field is for validation purposes and should be left unchanged.

Treatment Program Interested in

Children & Adolescent Programs
Adult Inpatient Programs
Adult Outpatient Programs

Demographics

Patient Name

Insurance

Guardian's Name
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Referring Provider's Name
Agency/Clinic/Practice Address

How did you learn about us?

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Reason For Referral

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How would you prefer to complete the level of care assessment?

Additional Information

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