Thrive Self Referral Form
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Trans Male
Trans Female
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
*
Ohio Medicaid
Caresource
Molina
Paramount
United Health Care
Buckeye Health
Aetna
Other / None
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?
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
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
Submit
Should be Empty: