Request for Assessment | Riveredge Hospital

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 708-209-4181. Licensed mental health professionals are available 24 hours a day, 7 days a week to assist you or your loved one.

Referral Information

Who are you referring?*

For Myself

Name*

First Last

Date of birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Best Time to Call*

:

Preferred Language*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

For My Relative/Loved One

My Relative/Loved One is:*

Child
Adult

Child

Are you the Legal Guardian?*

YES
NO

Legal Guardian Information

Legal Guardian Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Best Time to Call*

:

Preferred Language:*

Child's Name*

First Last

Date of birth*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

Referral Information

Referral Name*

First Last

Phone*

Email*

Relation to Child*

Best Time to Call*

:

Preferred Language*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

Adult

Referred by*

Name*

First Last

Date of birth*

Phone*

Email*

What services are you requesting?*

Initial Assessnent
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

For My Student

Referred by*

First Last

Email*

Phone*

School*

Relation to Student*

Student Age*

Student under the age of 17
Student over the age of 17

Student under the age of 17

Legal Guardian Name*

First Last

Phone*

Preferred Language*

Student Name*

First Last

Date of birth*

Grade Level*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

Student over the age of 17

Student Name*

First Last

Phone*

Date of Birth*

Preferred Language*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

For My Client/Patient

Referred by*

First Last

Email*

Phone*

Agency*

Relation to Patient*

Patient Age*

Patient under the age of 17
Patient over the age of 17

Patient under the age of 17

Legal Guardian Name*

First Last

Phone*

Preferred Language*

Patient Name*

First Last

Date of Birth*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

Patient over the age of 17

Patient Name*

First Last

Phone*

Date of Birth*

Preferred Language*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.

Other

Referred by*

First Last

Phone*

Email*

Relation to Referent*

Best Time to Call*

:

Preferred Language*

What services are you requesting?*

Initial Assessment
Outpatient Therapy
Psychiatry/Medication Management
Telehealth/Virtual Services
Other

Briefly describe the reason for your request.