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
Do you have a guardian? *

Yes No Unsure
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
Email Address (N/A if none)
email@emailaddress.com
Email Address
example@example.com
Home Phone

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County
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?
How did you hear about Thrive Behavioral Health? *

Referred by a Thrive employee Referred by an agency Website Word of mouth Social Media
Name of Thrive Employee: *
Name of Agency: *
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 Services School / Trade Schools Navigating legal system Building a support system Relapse Prevention Budgeting Basic 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)
What are the best days of the week for our staff to contact you? *

Monday Tuesday Wednesday Thursday Friday
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
If you have a copy of a current assessment and treatment plan indicating the need for Peer Support, please upload below.

Browse Files

Cancel of
Should be Empty:

Thrive Self Referral Form

Availability

Self-Reported Substance Use Assessment