Thrive Wellness Collaborative

Reason for care

What brings you to look for a therapist today?

(optional)

Limited to 600 characters

Administrative

Referral source

How did you find us?

Web Browser Search (google, ecosia, etc.) Psychology Today Referral from a Clinician Referral from a Friend Other

Billing & Payment

Will insurance be used to pay for sessions? If so, please list ALL insurance plans that the person seeking care is covered under, and specify if any plans are Medicaid. If a plan is Blue Cross, please check to see whether it is Blue Cross Blue Shield or Blue Care Network.

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

What exact windows are you available for standing appointments (same day on every week/every other week)? If you need week-by-week scheduling, please indicate that here.

For example; Mon: 8am-10am & 4pm-8-pm, Tue: none, Wed: all day.

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Preferred clinician

Select a clinician from the list

Do you have a preference for In-Person or Telehealth?

In-person Telehealth No preference

Is there anything that you would like us 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.

Who would be receiving care?

Your info