Therapy Intake Form (Adult)

Where/What are your Preferences for Therapy? (You can select multiple boxes)

Kenosha

Twin Lakes

Virtual

In-Person

Client Information

First Name

Preferred Name

Last Name

Date of Birth

Gender

If Adult Child (or if Insurance is Under Parent/Guardian)

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Parent/Guardian Contact Information (For Adult Child Only, If Different than Below)

Phone number

Email address

Mailing Address

City, State, Zip Code

Contact Information

Phone number

Email address

Mailing Address

City

State

Zip Code

Would you prefer your documents to be emailed, mailed, or come in person prior to your appointment to fill them out in person?

Emailed Mailed In-Person prior to the appointment date

Reasons for Visit

Describe the reasons you are seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

Mental Health History

Have you previously received therapy?

Yes No

If yes, what is the therapist's name and the name of the clinic in which you previously attended?

Have you previously, or are you currently being prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

If yes, what is the prescriber's name and the name of the clinic that previously/currently prescribes you medication?

Insurance Information

Please Note: If you do not provide any insurance information, we CANNOT assign you to a therapist until you do so.

Primary Insurance

Type "Self-Pay" under Insurance Company if you do not have insurance and are planning to pay out of pocket.

Insurance Company

Member ID

Group Number

If Medicare, Years of Eligibility

Provider Contact Phone Number

Please Specify Other

Secondary Insurance

Insurance Company

Group Number

Member ID

Provider Contact Phone Number

Please Specify Other

Tertiary Insurance

Insurance Company

Member ID

Group Number

Provider Contact Phone Number

Please Specify Other

How Did you Hear About Thrive Therapy Services?

Do you Have Any Preference for Therapist or any Specific Appointment Times that you Need?

Therapy Intake Form (Adult)

Emergency Assistance

Client Information

If Adult Child (or if Insurance is Under Parent/Guardian)

Parent/Guardian Contact Information (For Adult Child Only, If Different than Below)

Contact Information

Reasons for Visit

Mental Health History

Insurance Information

Primary Insurance

Secondary Insurance

Tertiary Insurance

Emergency Assistance