Therapy Intake Form (Child/Adolescent)

Thrive Therapy Services

Emergency Assistance

If this is an emergency, call:

Crisis Line: (262) 657-7188
911

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

Kenosha

Twin Lakes

Virtual

In-Person

Child's Information

First Name

Preferred Name

Last Name

Date of Birth

Gender

Legal Parent/Guardian Information #1

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Phone number

Email address

Mailing Address

City

State

Zip Code

If yes, what is the custody status of the child?

Describe Relationship between ALL legal parents and guardians.

Legal Parent/Guardian Information #2

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Phone number

Email address

Mailing Address

City

State

Zip Code

Contact Information

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 for the child.

Describe any goals or outcomes you hope that the child will achieve in therapy.

Describe any significant life changes or stressful events the child recently experienced.

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

Mental Health History

Has the child previously received therapy?

Yes No

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

Has the child been previously, or currently being prescribed psychiatric medication?

Yes No

If yes, what medications are they currently taking?

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

Insurance Information

Please Note: If you do not provide any insurance information, we CANNOT assign your child 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

How Did you Hear About Thrive Therapy Services?

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

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