Thrivewell | Connect

Please note: This form helps determine whether outpatient services may be a good fit. Submitting this form does not establish a therapeutic relationship.

First name

Last name

Phone number

Email

What kind of service are you seeking

Briefly describe why you are seeking services at this time.

If using insurance, who are you insured through?

Are you currently experiencing any of the following? If you are in crisis, please call 988 or go to the nearest emergency room.

Active suicidal thoughts

Recent psychiatric hospitalization

Immediate safety concerns

None of the above

I understand that this form is not an intake and is not monitored for emergencies.

Contact Misty

Contact
Misty