Thrive Self Referral Form

Thrive Self Referral Form
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Race *

White Black or African American Native Hawaiian / Other Pacific Islander Asian American Indian / Alaskan Native Unknown
Ethnicity *

Not Hispanic or Latino Hispanic or Latino Ethnicity Not Reported
Cell Phone *

Area Code Phone Number
Home Phone

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SS # *
Insurance Provider *
MMIS Number (found on insurance card)
Insurance ID / Policy Number
Do you have a mental health diagnosis? *

Yes No N/A
Mental Health Diagnosis (Type N/A if no diagnosis) *
How did you hear about Thrive Behavioral Health?
Comments
Self-Reported Substance Use Assessment
Primary Substance(s) *

Alcohol Cannabis Inhalants Sedatives Prescription Stimulants Methamphetamines Cocaine Opioids Hallucinogens N/A
Have you ever used for a longer time or a larger amount than originally intended? *

Yes No N/A
Have you ever tried to stop or control your use? *

Yes No N/A
Do you experience cravings? *

Yes No N/A
Does your use impact work, school, and / or home? *

Yes No N/A
Has your use impacted relationships with friends and / or family? *

Yes No N/A
Have you stopped doing things you enjoy because of your use? *

Yes No N/A
Does your use impact the safety of yourself or others? *

Yes No N/A
Do you continue to use despite of an impact on your mental and / or physical state? *

Yes No N/A
Have you gained a tolerance? *

Yes No N/A
Have you experienced withdrawal? *

Yes No N/A
Should be Empty:

Thrive Self Referral Form

Self-Reported Substance Use Assessment