Prescreening Form

Prescreening Form
Welcome to Thrive Behavioral Health

Please complete the information below. If you need help and additional information, please send an email to thrivecounselingjamaica@gmail.com or call (876) 833-5094.
Where did you hear about us?

Other
WHO IS COMPLETING THIS FORM?
Please state your full name:

First NameLast Name
Are you completing the form for yourself or someone else?
Please state your relationship to the client.

SAFETY FIRST!
Is there any current threat of suicide or homicide?
Is there any current threat of intimate partner or domestic violence?
CONSENT FOR SAFETY

A consent for safety gives your word you will not harm yourself or anyone else and that you are not in immediate danger. If you are completing this form for someone else, please select the appropriate consent on their behalf.
Can you consent to safety at this time?

WHAT PROGRAM AND SERVICES ARE YOU INTERESTED IN?

AT THRIVE BEHAVIORAL HEALTH, WE OFFER INDIVIDUAL THERAPY, COUPLES AND RELATIONSHIP COUNSELING, PREMARITAL COUNSELING, GROUP THERAPY FOR TEENS AND ADULTS AND INDIVIDUAL COACHING.
Let's get you connected to the right service! Please select the services that you are interested in receiving. Select all that apply.

TELL US ABOUT YOU/THE CLIENT!
Client's Information
CLIENT'S LEGAL NAME:

First NameLast Name
CLIENT'S PREFERRED NAME:
CLIENT'S DATE OF BIRTH:

MonthDayYear
Date
CLIENT'S SEX, GENDER, PRONOUNS
CLIENT PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
WHATSAPP PHONE NUMBER (If different)
Please enter a valid phone number.Format: (000) 000-0000.
CLIENT EMAIL:
example@example.com
Consent
Briefly tell us why you are seeking mental health services. Is there anything specific you want to focus on?
LET'S TALK
Has anything significant happened recently to cause these feelings?
How long have you been feeling this way?
Have you participated in mental health services before? If so, how long ago?
At some time, would you be interested in participating in a virtual support group? (Please indicate the specific group, if you are aware of one)

You are almost done! On the next page, you will be able to submit your form. Depending on the options you chose, you will be redirected to the next step.

If your responses don't require follow up from a Thrive professional, you will be redirected to our scheduling page. Make sure to choose the service you selected in this pre-screen. Remember to complete all intake paperwork at least 24 hours prior to your first appointment or you may be asked to reschedule. Thank you!
I agree that I have completed this accurately to the best of my knowledge.
Should be Empty:

Welcome to Thrive Behavioral Health