Become a client
Welcome to Thrive! Please complete this form to take the first step in working with a therapist at Thrive. This information will help us verify your insurance or discuss payment options. Within 24 business hours, we will send you a follow-up intake form to learn more about you and how we can support you so we can match you with the best therapist for your journey.
Personal Information
Name of Client
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
N/A
We request gender information solely for insurance verification purposes. At Thrive, we fully support and affirm all gender identities and expressions. Please provide the information that matches your insurance records.
Please provide days and times you ar available to see your therpist:
Insurance Information
Primary Insurance Co
Please Select
I will pay for therapy myself
Aetna
Anthem Blue Cross Blue Shield (PPO)
Boulder County Victims Compensation
Jefferson County Victims Compensation
Colorado Access Medicaid
Kaiser Permanente
Rocky Mountain Health Plans Medicaid
United Healthcare
Out-of-Network (Superbill for reimbursement)
Other
If you don’t see your insurance company listed, we don’t currently accept your insurance. We can still help you find a licensed therapist if you can pay for therapy yourself (some plans will reimburse you for the sessions).
Policy No
*
Group No
Subscriber's Name if different than Client (ie Parent, Child or Spouse)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
If there is a specific therapist you would like to work with, please let us know:
Please Select
Brynn Miller Hakon
Amy Porter
Margarita Mironova
Martina Holzach
Christine Mangum
Andrew O'Reilly
Krystel Mairs
Sydney Leto
Monica Posada
Leda Swann
Kiera Butler
Jessie Westbrook
Eve Beilovei
Dr. Noah Goldstein (acupuncture, private pay)
If they have availability, we will do our best to schedule you!
Notes that may be relevant to the verification process
**Our followup intake form will ask specifics around your mental health needs. This form is only for insurance and payment verification purposes**
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Submit
By providing your consent, you agree to receive text (SMS) messages and emails from Thrive at the contact information provided. We are committed to keeping all your information private and confidential, in compliance with HIPAA regulations. You acknowledge that you understand the risks associated with electronic communication and agree to participate in these services for appointment reminders, scheduling, and other relevant communication.
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