Referral - Heal Thrive Grow Behavioral Health

Is this client returning for services?

No, the client is new to THRIVE
Yes, the client has previously received treatment at THRIVE

Referring Party

Relationship to client

Agency

Name of person referring client

First Last

How did you hear about Heal THRIVE Grow Behavioral Helath

Address of person or agency referring client

Street Address Address Line 2 City State ZIP Code

Phone number of person or agency referring client

Extension

Ok to leave a message?

Yes, please leave a message
Please, do NOT leave a message

Email of person or agency referring client

Additional comments

Client Information

Legal name

First Last

Preferred name

Age

Date of birth

Date format must be MM/DD/YYYY

Parent name(s) if under 18 years old

Gender

Female
Male
Trans

Preferred gender identity

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Secondary phone number

Is it ok to leave a message?

Yes, please leave a message
Please, do NOT leave a message

Email

You will not be added to an email list - email will be used to update wait list status, follow up if we are unable to reach you by phone, or provide scheduling information.

How did you hear about Heal THRIVE Grow Behavioral Health

Medication Management Services

We are proud to offer medication management services at THRIVE by staff trained in the evidence based psychotherapy model and integrated into our treatment teams. Receiving medication management services at THRIVE will allow for frequent and effective collaboration between your prescriber and therapist. Are you interested in scheduling a session with a medication provider?

Yes, I am interested in medication management services.
Not at this time.

Nutrition Therapy

We understand the importance of nutrition therapy in treating a variety of eating probles, and provide comprehensive nutrition counseling on-site. A registered, licensed dietitian, provides all nutrition services. These individualized sessions are structured to assist clients in developing healthy eating habits and relationships with food and provide opportunities to discuss food-related issues, set nutrition goals, increase intuitive eating skills, and receive personalized nutrition recommendations. Are you interested in scheduling a session with a nutritionist?

Yes, I am interested in nutrition therapy
Not at this time

The more limited your availability, ie after school only, the longer the wait may be to place you in our program.

I understand

Appointment availability (check all that apply)

Morning
Afternoon
After school
Evening

Do you have a STRONG preference for therapist gender? Note: this will increase the wait time to be placed in our program.

I do not have a strong preference and would like to be placed as quickly as possible
I strongly prefer a FEMALE therapist
I strongly prefer a MALE therapist

Reasons or Concerns for Seeking Treatment

Please indicate if you are interested in any of the following groups.

CBT for Insomnia Group
Couples Skills Workshop

Have you been experiencing symptoms of anxiety?

For example, difficult-to-control worrying, avoidance of people/places/objects that interferes with your life, panic attacks, intrusive memories of past traumatic events.

Yes
No

Check all that apply

Difficult-to-control worry, most of the day
Sudden rushes of anxiety or what some might refer to as a “panic attack”
Feeling anxious or fearful when you go out of your house alone
Feeling very anxious in social situations, especially with people you don’t know well
Intrusive memories, nightmares, or other experiences subsequent to witnessing or being involved in a traumatic event (fire, unexpected death, violence, etc).
Specific objects or situations that make you extremely afraid (i.e. insects, blood/injections, heights, closed spaces).

On average, how often are you worrying during the past 6 months ?

Once a month
Once a week
Multiple times per week
Every Day

Please list the objects or situations that make you extremely afraid (i.e. insects, blood/injections, heights, closed spaces).

How long have you had difficulty with anxiety/worries?

Only the past week
Only the past month
Greater than 6 months
Most of my life

Have you had difficulty sleeping?

For example, difficulty falling asleep, feeling unrested upon awakening, difficulty using a CPAP machine while sleeping, recurrent nightmares.

Yes
No

How long have you had sleep difficulties?

Less than 1 month
1-3 months
3-6 months
More than 6 months

Check all that apply:

Difficulty falling asleep, waking during the night, or waking up too early
Not feeling rested after sleep
Feeling fatigued or sleepy during the daytime
Difficulty adjusting to my CPAP machine
Recurrent unpleasant or upsetting dreams or nightmares

How often are you experiencing unpleasant or upsetting dreams or nightmares?

Less than once a week
One or two nights a week
Three or more nights a week
Every night

Have you been experiencing symptoms of depression?

For example - Low mood (feeling blue or sad), irritability, fatigue/low energy, low motivation, feeling guilt, experiencing negative self talk, or hopelessness.

Yes
No

Over the LAST 2 WEEKS, how often have you been bothered by the following problems?

Little Interest or pleasure in doing things.

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless.

Not at all
Several days
More than half the days
Nearly every day

Trouble falling asleep or staying asleep, or sleeping too much.

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy.

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself - or that you are a failure or let your family down.

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television.

Not at all
Several days
More than half the days
Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way.

Not at all
Several days
More than half the days
Nearly every day

Self-harming behaviors?

Yes
No

Behaviors

Burning
Cutting
Picking
Other

Other self-harming behavior

Suicidal thoughts?

Yes
No

How often?

Suicide attempts in the past 6 months?

Yes
No

Date of most recent attempt?

Hospitalized in the past year for mental health reasons?

Yes
No

Date of most recent hospitalization?

Has there been any legal involvement in your mental health?

For example: you have been ordered by a judge, parole officer, etc. to seek mental health treatment.

Yes
No

Please describe the legal involvement in your mental health.

Eating disorder concerns?

Yes
No

Behavior (check all that apply)

Bingeing
Purging
Restricting
Over exercise
Other

Other form of eating disorder

Purging

Laxatives
Vomiting
Both laxatives and vomiting

Do you have a PCP

Yes
No

Name address and phone number for your PCP

Alcohol or drug abuse?

Yes
No

Please describe the substance abuse

History of Traumatic Events?

Yes
No

Posttraumatic Checklist - In the past month, how much were you bothered by:

Repeated, disturbing dreams of the stressful experience?

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

Feeling very upset when something reminded you of the stressful experience?

Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

Avoiding memories, thoughts, or feelings related to the stressful experience?

Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

Trouble remembering important parts of the stressful experience?

Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: l am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

Blaming yourself or someone else for the stressful experience or what happened after it?

Having strong negative feelings such as fear, horror, anger, guilt, or shame?

Loss of interest in activities that you used to enjoy?

Feeling distant or cut off from other people?

Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

Irritable behavior, angry outbursts, or acting aggressively?

Taking too many risks or doing things that could cause you harm?

Being "superalert" or watchful or on guard?

Feeling jumpy, or easily startled?

Trouble falling or staying asleep?

Total

$0.00

Insurance Information

Lyra Health Subscriber’s Name

Lyra Health Subscriber’s Date of Birth

Name of Lyra Health Subscriber’s Employer

Acknowledgement

By checking the box below I acknowledge that THRIVE does not currently bill commercial insurance, with the exception of Lyra Health, and that all costs must be paid out of pocket at the time of treatment. Furthermore, I understand that I can request an invoice from THRIVE to submit to my insurance (if applicable), though my insurance may not cover any of the costs of my treatment at THRIVE. I have revceived the 4 step process for submitting invoices to insurance companies at the "Getting Started" page of www.healthrivegrow.com

I Understand

Menu

Client Information

Reasons or Concerns for Seeking Treatment

Over the LAST 2 WEEKS, how often have you been bothered by the following problems?

Posttraumatic Checklist - In the past month, how much were you bothered by:

Insurance Information

Our Sister Organization