EXTERNAL Thrive Peer Support Referral Form

Refer a Client

Please contact us with any questions 1-877-636-3777
If available, please provide a current treatment plan indicating a need for peer support and current agency assessment.

Documents can be uploaded at the bottom of this form, or can be faxed/emailed to the addresses provided below. Referrals to peer support services should be discussed with the client prior to completing this referral form.
I have read and understand the above statement
Referral Source Info
Name of Person Completing Referral*

Writer First NameWriter Last Name
Organization*
Other please specify:
Phone Number of Person Completing Referral:*
Email Address of Person Completing Referral:
Your relationship to the client: *
Client Info
Client Name*

Client First NameClient Last Name
DOB (mm-dd-yyyy)*

MonthDayYear
Does the peer 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
Is the peer in need of any translation services? If so, what type (Examples: American Sign Language, Spanish, French, Etc.)?
Peer Home Phone
Peer Cell Phone*
Peer Email Address (type N/A if none)*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Social Security Number*
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
Policy Number
MMIS Number
Member ID Number
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
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
Diagnosis Info
Does client have substance use disorder?*

YesNoN/A
Please enter the primary substance use diagnosis code (ICD-10)*
Example: F12.20
Primary substance use diagnosis description:*
Example: Cannabis use disorder, moderate, in sustained remission in a controlled environment
Primary diagnosis provider:*
Example: Dr. Strange
Primary Provider Credentials:*
Example: LISW
Facility: *
Example: General Hospital
Does the client have a secondary/additional substance use diagnosis?*

YesNo
Please enter the secondary/additional substance use diagnosis code (ICD-10)*
Example: F12.20 (You can list them using commas if there is more than one additional diagnosis.)
Secondary/Additional substance use diagnosis description:*
Example: Cannabis use disorder, moderate, in sustained remission in a controlled environment
Secondary/Additional diagnosis provider:*
Example: Dr. Strange
Secondary Provider Credentials:*
Example: LISW
Secondary Facility: *
Example: General Hospital
Client identifies as previous use of:*

AlcoholCannabisCocaineInhalantsSedativesOpioidsPrescription StimulantsMethamphetaminesHallucinogensN/AOther
Has the client had previous criminal justice involvement?*

YesNoUnknown
Court client involved in
Probation Officer
Does client have a mental illness?*

YesNoUnknown
Please enter the primary mental health diagnosis code (ICD-10)*
Example: F31.76
Primary mental health diagnosis description:*
Example: Bipolar I Disorder, Current or most recent episode depressed, In full remission
Primary diagnosis provider:*
Example: Dr. Strange
Credentials:*
Example: LISW
Facility: *
Example: General Hospital
Does the client have a secondary mental health diagnosis?*

YesNo
Please enter the secondary mental health diagnosis code (ICD-10)*
Example: F22
Secondary mental health diagnosis description:*
Example: Delusional Disorder, With bizarre content, The following course specifiers are only to be used after a 1-year duration of the disorder: Multiple episodes, currently in partial remission
Secondary diagnosis provider:*
Example: Dr. Strange
Credentials:*
Example: LISW
Facility: *
Example: General Hospital
Psychiatrist/Counselor
How much Peer Support are you requesting for your client on a weekly basis?

0-5 hours6-10 hours11-15 hours16+ hours
Recovery Support Service(s) or Treatment Service(s) Requesting:

Daily Life SkillsEmployment servicesSocial InteractionsMedical AppointmentsOther
Emergency Contact Information
Other Pertinent Contact Information (Case worker, counselor, house manager, etc.)
Comments
Please include a copy of the client's current Treatment Plan and assessment indicating the need for Peer Support.

Browse Files
This information can also be emailed to referrals@thrivepeersupport.com or faxed to 216-220-3204 Cancelof
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Refer a Client

Referral Source Info

Client Info

Availability

Diagnosis Info