Therapy Intake Form (Couples)

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

Significant Other 1's Information

First Name

Preferred Name

Last Name

Date of Birth

Gender

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

Significant Other 2's Information

First Name

Preferred Name

Last Name

Date of Birth

Gender

Phone number

Email address

Contact Information (If Different than Above)

Mailing Address

City

State

Zip Code

Please Specify Other

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 or your significant other have recently experienced.

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

Therapy 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?

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

Specify Other

Secondary Insurance

Insurance Company

Group Number

Member ID

Provider Contact Phone Number

Specify Other

Tertiary Insurance

Insurance Company

Member ID

Group Number

Provider Contact Phone Number

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?

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