Client Registration & Consents

Account

First Name

Last Name

Email

Phone

Password

Confirm Password

Demographics

DOB

Age

Gender

Street

City

State

Zip

County

Preferred Therapist (optional)

Required Consents

Consent for Treatment/Services

I hereby consent to Thrive Integrative, Inc. to provide mental health services, including assessment, counseling, medication management, case management, crisis intervention, and related services. (Summary of form.)

I agree and consent to treatment.

Authorization for Disclosure (DHS)

I authorize Thrive Integrative, Inc. to disclose/obtain information with Illinois DHS agencies for purposes of verification and continuity of care. I understand my right to revoke, and the redisclosure limitations. (Summary of form.)

I authorize as described.

Client Rights Statement (Acknowledgment)

I acknowledge receipt and understanding of the Client Rights Statement of Thrive Integrative, Inc.

I acknowledge the Client Rights Statement.

Insurance / Plan

Insurance Type

Insurance # / MedRin (if any)

New Client Registration