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Child & Adolescent Programs
Acute Psychiatric Care
Adolescent Male Extended Care Unit
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Referral Form
uhs@RBHSA
2026-06-01T17:46:08+00:00
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Referral Form
Referral Form
Admissions Referral Form
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Treatment Program Interested in
Adult Acute Psychiatric Inpatient Program
Adult Inpatient Dual-Diagnosis/Co-Occurring Mental Health & Substance Use Treatment program
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)
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)
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
How did you learn about us?
How did you learn about us? choices
Current Therapist/Outpatient Provider
Physician/Nurse/Therapist
School
Hospital
Social Media
Website/Google
Family/Friend
Other
Provider Name
Agency/Clinic/Practice Name
Reason For Referral
Reason for Referral choices
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
Additional Information
Notes
Supporting Documents
Max. file size: 50 MB.
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
Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 15.
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