Thrive Mental Health Services

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

Inquiry reason

PLEASE READ- NEXT STEPS:

*PLEASE FO NOT USD THIS PRESCRENER to book a "call" with me. Instead please email me ag therapy@thrivemhs.com & confirm you have completed it. I will then review your Prescreener Responses, and if you would be a good fit clinically, etc. I will then change your status from "Prospective Client" to "Active Client". And via email I will send you specific instructions re Next Steps.

Billing & Payment

PAYER SOURCE QUSTIONS:

How do you plan to pay? Select all that apply

Insurance Employee Assistance Program (EAP) Out of pocket (Self-Pay)

Insurance details

Please state what Insurance you will be using- the name on the top of the card.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

PAYER SOURCE: If using Insurance, who is the Primary Insured & What is their relationship to the Client?

(ex: self, parent, spouse, legal guardian)

Limited to 600 characters

PAYER SOURCE: If using an EAP, what is the name of the EAP?

If using an EAP, please be Specific about what EAP Network you want to use. (If not using an EAP, just type NA)

Limited to 600 characters

If using an EAP, who is the Employee and what is their relationship to the Client?

(if not using an EAP, just type NA)

Limited to 600 characters

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Preferred "Location" (In-Person/ Via Telehealth/ open to BOTH)

In-person (NOTE: only available on Mondays, Thursdays, & Fridays) Telehealth (NOTE: Generally available M-F) BOTH

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.