Highland Rivers Community Service Board
Agency Referrals

REFERRAL FORM - Child & Adolescent Program

Thank you for your referral. Highland Rivers is committed to providing excellent care to our communities and we appreciate the opportunity to serve.

Please open the Referral form by clicking the link below. Save the completed referral to your desktop and return it as an email attachment to referrals@highlandrivers.org .

If you prefer, you may also fax your survey directly to your nearest Highland Rivers' clinic.

Highland Rivers Referral

For a listing of clinic fax numbers please click here.

REFERRAL FORM - Child & Adolescent Crisis Stabilization Program

The Highland Rivers Community Service Board (HRCSB) Child and Adolescent Crisis Stabilization Program (C&A CSP) is a medically monitored, short term crisis stabilization program that provides psychiatric stabilization and detoxification from alcohol and/or drugs for children and adolescents. The C&A CSP is designated as an Emergency Receiving and Evaluating Facility.

The program operates 24 hours a day, 7 days a week, and is located at:

705 North Division St., Building 315
Rome, GA 30161
Phone number 706-802-5870
Fax number 706-802-5921

The C&A CSP Management Team includes:

Carla Simmons, RN, BSN, Nurse Manager
Nasira Rubina, MD, Child & Adolescent Psychiatrist
Stephanie White, LPC, Clinical Coordinator
Ann H. Davies, LCSW, Director, 706-270-5100 or 706-280-7558

Enclosed for your use when referring children and adolescents to the C&A CSP is our Admission Criteria, Initial Laboratory Screening Requested for Referrals and the Pre-Admission Referral Form, to be competed and faxed to the C&A CSP Unit for all referrals.

Please call the unit anytime, 24 hours a day, if you have a question about referrals of children and adolescents to our C&A Crisis Stabilization Program.

REFERRAL FORM - PRTF and Community Transition Planning

Sometimes children's symptoms and behaviors are so severe they need a specialized hospital to provide 24-hour care, diagnosis, and treatment. In Georgia, six Psychiatric Residential Treatment Facilities (PRTFs) have the primary function of diagnosing and treating patients with severe psychiatric disorders who are eighteen years old or younger.

As a Core Provider, Highland Rivers provides assistance to families and service providers who need PRTF placement. Highland Rivers also provides Community Transition Planning (CTP) to help assure that children make successful transitions home from residential treatment.

Please click on the links below for important forms and information. For questions contact Donna Robbins, C&A Residential Coordinator at 770-547-7110 or donnarobbins@highlandrivers.org.

PRTF Admission Checklist and Cover Sheet
PRTF Process for Medicaid and FFS
PRTF Admission Review for Medicaid and FFS
PRTF Admission for Magellan
Highland Rivers Community Transition Planning Referral Form