Thrive Behavioral Health Request for Services

Thrive Behavioral Health Request for Services

(HIPAA Compliant Referral Form)
We are so glad you reached out and look forward to getting to know you! If this form is too long or you have a question, please don't hesitate to reach out to one of our intake coordinators. Their numbers are listed below and they are happy to help! This on-line request for services is NOT for urgent help as it is checked frequently, but not on an emergency basis.

If your needs are urgent or someone is in danger of hurting themselves or others, please call 911 and let them know it is a mental health emergency, go to the emergency room or call a crisis response hotline at a number below:

Anne Arundel County Crisis Response: 410-768-5522
Baltimore City Crisis Response: 410-433-5175
Baltimore County Crisis Response: 410-931-2214

Frederick County MHA: 211 or 866-411-6803
Harford County Crisis Response: 1 (800)-639-8783
Howard County Crisis Response: 410-531-6677
Montgomery County Crisis Response: 240-777-4000
Prince Georges County Crisis Response: 301-429-2185
The Trevor Project (Crisis Intervention and Suicide Prevention Services for LGBTQ+ Community): 866-488-7386
To confirm, the client does not have any thoughts or plans to harm themselves, does not have any thoughts or plans to harm others, and is not having any type of hallucinations?*

That is right! Everyone is safe and I understand this referral is not for urgent needs. If that changes, I will contact the crisis numbers above.No, the client has thoughts or plans to harm themselves and I will contact a crisis number above for urgent help.No, the client has thoughts or plans to harm others and I will contact a crisis number above for urgent help.No, the client is having some type of hallucinations and I will contact a crisis number above for more urgent help.I am not sure, but will contact a crisis line above to see if the issue is urgent. I understand this on-line referral is not for urgent or crisis help.
I understand that our Rosedale and Catonsville offices currently do not have openings for in person services unless in a school that we have a partnership with.*

YesNo, I understand I can contact my insurance company for another provider. Some other agencies who may have evening availability are: Families First at 240-304-3327, Leading By Example at 410-780-2692, Aspire at 443-442-1568 or Brighter Stronger Foundation at 410-574-000.
I understand that Thrive currently only has open availability for day time appointments. There may be some limited availability for telehealth, evening appointments. Thrive will do our best to meet evening Telehealth only needs and will communicate to you as quickly as possible if we are not able to accommodate this scheduling need.*

YesNo, I understand I can contact my insurance company for another provider. Some other agencies who may have evening availability are: Families First at 240-304-3327, Leading By Example at 410-780-2692, Aspire at 443-442-1568 or Brighter Stronger Foundation at 410-574-000.
I understand that: In-Person, evening appointments are not guaranteed. Thrive will do our best to meet evening only needs and will communicate to you as quickly as possible if we are not able to accommodate this scheduling need. Most open evening appointments currently are Telehealth*

YesNo, I understand I can contact my insurance company for another provider. Some other agencies who may have evening availability are: Families First at 240-304-3327, Leading By Example at 410-780-2692, Aspire at 443-442-1568 or Brighter Stronger Foundation at 410-574-000.
Depending on availability and clinical match, Thrive MAY be able to assign for in-person services in our office OR for telehealth before 5 p.m. Once an evaluation is completed, we can work to match you with a therapist with this availability, but can not guarantee afternoon/evening or in-person and may have to defer to telehealth appointments during the day time.*

YesNo, I understand I can contact my insurance company for another provider. Some other agencies who may have evening availability are: Families First at 240-304-3327, Leading By Example at 410-780-2692, Aspire at 443-442-1568 or Brighter Stronger Foundation at 410-574-000.
Who is completing this form?*

Adult client seeking services for myself16 or 17 year old seeking services for myselfParent or legal guardian seeking services for a childFriend or loved one seeking services for someone else. I understand that if Thrive contacts the person, Thrive may not be able to share details without that person's permission.School based professional in Baltimore City, Baltimore County, Carroll County, or Harford County. I have gotten permission from parent/guardian to contact Thrive on their behalf.School based professional in Anne Arundel, Howard, Prince Georges, or Montgomery Counties. I have gotten permission from parent/guardian to contact Thrive on their behalf.School based professional in Frederick County. I have gotten permission from parent/guardian to contact Thrive on their behalf.Other professional seeking services for a patient, client, student, or other community member. I have gotten permission from them to contact Thrive on their behalf.
An electronic confirmation email that your referral was received, please enter that email below:
example@example.com
Does the client have Medicaid coverage? Thrive currently has a wide availability of clinicians able to provide services to clients with Medicaid. We do not have availability for Medicare services at this time.*

MedicaidOther-- Unfortunately, Thrive does not have openings for other insurance coverage at this time.Client attends a school that has a Thrive therapist who can take private insurance. Intake coordinator will contact family to inquire about private insurance status.
Has the client received services elsewhere*

Yes, at Thrive.Yes, at another provider. I understand Thrive can not provide services until I have told the insurance company I am not going to that provider anymore by calling 1-800-888-1965. (The insurance company is taking up to 14 days to make this change and may prevent Thrive from getting started right away.)NO
Client Name (Name that is on file with client's insurance company). Thrive must use this name for billing and accounting purposes. This name will appear on any communication related to billing/accounting.*

First NameLast Name
Front of Insurance Card

Browse Files

Cancelof
Back of insurance card

Browse Files

Cancelof
What is the clients identified name, if different from the one listed above? We will work hard to use this name during all communications with the client.
Preferred Name
What name would you like to appear on letters sent to clients home and/or reminder calls?
Date Of Birth*

MonthDayYear
Date
Social Security Number
This is a HIPAA compliant referral form and this number will be kept private and confidential.
MA/ Medicaid Number
(MA numbers are 11 digits long.)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Number *
Would you like to receive text reminders for upcoming appointments?

YesNo
Other Phone Number
Email
example@example.com
What gender does the insurance company have on file? (Required by insurance company)*

MaleFemale
What is the identified gender of the client?
Do you identify as another gender identity? If so, please let us know and we will add it to our options!
What pronouns does the client use?
What is the client’s race?
Is the client Hispanic, Latino/a, or Spanish origin?

YesNo
Parent or Guardian Information:

(If client does not have a parent or legal guardian to list, please skip to the REFERRAL PERSON/AGENCY section).
- For minor clients 15 and under, legal guardian must complete intake paperwork and provide proof of guardianship in order for minors 15 and under to be seen for services.
- Legal guardians must show proof of guardianship, such as a birth certificate, custody paperwork, kinship care affidavits, or other legal documents prior to or at intake.
- Legal guardians must be present for intake and, if applicable, for psychiatric evaluations and follow up medication management appointments.
- DSS and DJS workers should contact the office directly for more information on specific process.
- In the state of Maryland individuals 16 and over may consent for mental health treatment, but Thrive requires a parent or guardian for medication management consent.
Is the client a minor who will be signed into treatment by a legal guardian? If not, please skip to Referral Agency section.*

YesNo
Legal Guardian Name

First NameLast Name
Legal Guardian Name (If more than one legal guardian)

First NameLast Name
Guardian Relationship
If legal guardianis a DSS or DJS agency, please specify worker's name and agency.
Home Number (If different than contact number listed above for client)
Mobile Number(If different than contact number listed above for client)
What other languages are spoken at home by the client or parent/guardians?

NoneEnglish OnlySpanishPortugeseFrenchArabicOther
Email
example@example.com
Home

HomeGroup HomeShelterFoster CareHomelessOther
Referral Agency/Person

If client is seeking services for themselves or their child, please skip down to QUESTIONS section.
Name

First NameLast Name
Relationship
Agency/School*
Are you requesting school based services?*

YesNo
Email
example@example.com
Office Number
Mobile Number
Questions

Thrive Behavioral Health wants to make sure we are the best provider for you to connect with. Please answer the following questions so we can reach out regarding our services or connect with you a provider that is the best fit for your needs.
What are the reasons you are looking for help from Thrive Behavioral Health?*

AnxietyTrauma ReactionImpact of racial traumaImpact of gender or sexuality bias and related traumaDepressionManaging angerMood changesBehavioral concernsProblems coping with work or schoolThoughts or actions of wanting to harm or kill self (Please see crisis information above!)Thoughts or actions of wanting to harm or kill others (Please see crisis information above!)HallucinationsSelf-harmFamily discordTreatment that incorporates an understanding of spiritualityTreatment that incorporates an understanding of racism and discriminationTreatment that incorporates an understanding of issues important to the LGBTQ+ communityAttention and/or impulse control difficultiesOther
Does the client have thoughts or plans to harm or kill themselves?*

YesNo
Does the client have thoughts or plans to harm or kill someone else?*

YesNo
Does the client have any type of hallucinations?*

YesNo
Is there domestic violence in the home?*

Yes (House of Ruth offers great support: https://houseofruth.org/about-us/)No
Is there someone who has displayed sexually aggressive behavior or is a registered sex offender residing in the home?*

Yes (If someone is in immediate danger, please contact a crisis line above.)No
Is the client violent towards others?*

Yes (If someone is in immediate danger, please contact a crisis line above.)No
Does the client use alcohol or use drugs to the point it causes a problem for them or others?*

Yes (National Helpline at 1-800-662-HELP is a 24/7 hotline that can offer support)No
Does client have access to a device and internet for telehealth when needed? If not, Thrive will do our best to help!*

Yes, client has both a device and internet access.No device, but has access to internet.No internet, but has access to a computer, tablet, or smart phoneNo device or internetNot interested in telehealth at this timeOther
What is your preference for location?

Telehealth (depends on whether insurance company allows telehealth at that time)Home or other community location (limited availability; can not be guaranteed)School (only permitted in partnership schools)Thrive officeOther
What is the primary language spoken by the client?
Is the client or parent/guardian blind, deaf or have another ability status that Thrive can make sure to accommodate in order to make your experience positive and supportive?

YesNo
If so, please describe:
Which area does the client live in?*

Anne ArundelBaltimore CityBaltimore CountyCarroll CountyFrederick CountyHarford CountyHoward CountyMontgomery CountyPrince Georges CountyCecil CountyQueen Anne's CountyOther
Optional: If you have a specific therapist that you are requesting, please enter their name below:
What happens next?
- Our intake coordinators will process the request for services. If there is missing information or we have another question, we will contact you within 3 business days.
- Once your request is processed, an Intake Clinician will be assigned.
- The Intake Clinician will call to schedule an intake.
- The intake takes between 1 to 2 meetings. Our Intake Clinicians will walk you through important steps, including who you would like us to be able to communicate with, understanding why you reached out to us, what you would like help with, and getting an understanding of both what are the challenges and strengths in various parts of life that may (or may not!) be part of finding solutions.
- At the end of the intake process, our Intake Clinicians willmake a recommendationon what types of services will be the best fit. We will make that recommendation and, if our services seem like a good fit, we will assign a clinician to work on an on-going basis. If indicated, the clinician can assist with scheduling for a psychiatric evaluation.
- If you have questions please prior to being contacted by an intake clinician, please call us and we will do our best to help! We have clinicians who may be available same day.
Who do I call if I have more questions?
You can call one of our intake coordinators. They are happy to help!

AA County, PG County, Mo. County and Howard Country:

Melissa Klaus (mklaus@thrivebh.com) Tel: 410-780-5203 Fax: 410-987-4301

Baltimore City, Baltimore County and Harford County Referrals:

Adrianna Ramos(amoore@thrivebh.com) Tel: 410-780-5203 Fax: 410-780-5205

Baltimore School Referrals:

Adrianna Ramos (amoore@thrivebh.com) Tel: 410-780-5203 Fax: 410-780-5205

Harford County School Referrals:

Adrianna Ramos (amoore@thrivebh.com) Tel: 410-780-5203 Fax: 410-780-5205

Cecil County School Referrals:

Adrianna Ramos (amoore@thrivebh.com) Tel: 410-780-5203 Fax: 410-780-5205
Should be Empty:

Thrive Behavioral Health Request for Services

Parent or Guardian Information:

Referral Agency/Person

Questions

What happens next?

Who do I call if I have more questions?