THRIVE Psychiatric Care | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Administrative

Referral source

Tell us how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay for your visits with THRIVE?

Insurance Details

If you are planning to utilize insurance for your visits with THRIVE please tell us your insurance provider and upload a copy of your insurance card below. Please see our website for a list of insurances we accept.

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Insurance card upload

Upload a photo of your insurance card

Who is the primary insurance policy holder?

Self Spouse Parent

Please provide the following information for the primary insurance policy holder: Full name, date of birth, sex, address and phone number.

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Client Preferences

Preferred clinician

Select a clinician from the list

Preferred modality

What would you like the practitioner to know about why you are seeking care with THRIVE Psychiatric Care??

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.