RTC Request - Eating Disorder or Mental Health


Please complete all parts as clearly and as specifically as possible. Omissions, generalities and illegibility will result in the form being returned for completion or clarification and not be considered a complete request.

*Please do not use this form for RTC Substance Use requests. Use the Facility Based Treatment Form for RTC Substance Use requests.

Patient Information
Address Where Services Are Being Rendered
Facility Contact Number () -
UR Phone Number () -
UR/Facility Fax Number () -
Facility Information
Referring Physician's Address
Clinical Information

Facility is primarily providing a continuous structured therapeutic program specifically designed to treat behavioral health disorders and is not a group or boarding home, boarding or therapeutic school, half-way house, sober living residence, wilderness camp or any other facility that provides Custodial Care.***

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What attempts have been made to treat the patient with the maximum intensity of services available at a less intensive level of care, especially within the past six months?

Current Psychiatric Medications
Past Psychiatric Medication Trials
Substance Abuse
Max characters: 2000
List goals necessary and attainable for the patient/family within a Residential Treatment Setting. Treatment duration may be several months:
Max characters: 300
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Family Therapy Requirements for age 18 and under:
The custodial parent/family is required to participate in weekly, on-site family therapy. If due to hardship, however, parents are unable to attend on-site, weekly family therapy must occur, with appropriate documentation, using remote technology-assisted