Thrive Self Referral Form

Thrive Self Referral Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Do you have a guardian?*

YesNoUnsure
Gender*
Race*

WhiteBlack or African AmericanNative Hawaiian / Other Pacific IslanderAsianAmerican Indian / Alaskan NativeUnknown
Ethnicity*

Not Hispanic or LatinoHispanic or LatinoEthnicity Not Reported
Are you in need of any translation services? If so, what type (Examples: American Sign Language, Spanish, French, Etc.)?
Cell Phone*

Area CodePhone Number
Do you give Thrive permission to reach out via text message to coordinate care?*

YesNoN/A
By selecting yes above, I understand that I may opt-out of receiving these communications from Thrive at any time by calling the mainline at 1-877-636-3777 and speaking with a Thrive representative, or by texting 'STOP' to text messages sent by Thrive.
Email Address (N/A if none)
email@emailaddress.com
Email Address
example@example.com
Home Phone

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
SS #*
The correct social security number for the client is required to confirm insurance information. Without the correct number we cannot process this referral, or start services for the client.
Insurance Provider*
MMIS Number (found on insurance card)
Insurance ID / Policy Number
Member ID Number
Do you have a Substance Use Disorder diagnosis?*

YesNoN/A
Substance Use Diagnosis*
Do you have a mental health diagnosis?*

YesNoN/A
Mental Health Diagnosis*
How did you hear about Thrive Behavioral Health?
How did you hear about Thrive Behavioral Health?*

Referred by a Thrive employeeReferred by an agencyWebsiteWord of mouthSocial MediaOther
Name of Thrive Employee:*
Name of Agency:*
Are you currently enrolled in or participating in IHBT services (Intensive Home Based Treatment)?*

YesNo
Are you currently enrolled in or participating in ACT services (Assertive Community Treatment)?*

YesNo
I am interested in peer support to aid and assist my recovery with:*

Establishing a recovery pathway (i.e-12 steps, SMART recovery, Medication Assisted Treatment, faith based, etc.)Employment ServicesSchool / Trade SchoolsNavigating legal systemBuilding a support systemRelapse PreventionBudgetingBasic needs (housing, clothing, food)Mental health needs
Availability
What are the best times of day for our staff to contact you?*

Morning (8:30a - 12:00p)Afternoon (12:00p - 4:30p)Early Evening (4:30p - 6:30p)Other
What are the best days of the week for our staff to contact you?*

MondayTuesdayWednesdayThursdayFridayOther
Comments
Self-Reported Substance Use Assessment
Primary Substance(s)*

AlcoholCannabisInhalantsSedativesPrescription StimulantsMethamphetaminesCocaineOpioidsHallucinogensN/AOther
Have you ever used for a longer time or a larger amount than originally intended?*

YesNoN/A
Have you ever tried to stop or control your use?*

YesNoN/A
Do you experience cravings?*

YesNoN/A
Does your use impact work, school, and / or home?*

YesNoN/A
Has your use impacted relationships with friends and / or family?*

YesNoN/A
Have you stopped doing things you enjoy because of your use?*

YesNoN/A
Does your use impact the safety of yourself or others?*

YesNoN/A
Do you continue to use despite of an impact on your mental and / or physical state?*

YesNoN/A
Have you gained a tolerance?*

YesNoN/A
Have you experienced withdrawal?*

YesNoN/A
If you have a copy of a current assessment and treatment plan indicating the need for Peer Support, please upload below.

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Thrive Self Referral Form

Availability

Self-Reported Substance Use Assessment