ThrivePointe | SimplePractice

ThrivePointe Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Parenting Other

What type of counseling are you seeking?

Individual Adult Therapy Child Therapy Adolescent Therapy Couples Therapy Family Therapy Parent Skills Training Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Inquiry reason

Referral source

How did you find out about ThrivePointe?

Is the client a minor whose parents have a custody or visitation agreement?

If yes, be prepared to upload custody documents after you accept our invitation to the client portal.

Yes No

Billing & Payment

Payment method

We do not accept insurance. Our clients self-pay at the time of service. What payment method do you plan to use?

Client Preferences

Preferred appointment times

Morning Afternoon Evening No preference

Preferred clinician

Select a clinician from the list

No results found.

Preferred modality

Is there anything that the therapist needs to know?

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

Limited to 600 characters

Preferred method of contact

Email Phone No preference

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.