Client Information The person receiving service
Please describe the client's availability. Provide specific days and times.
Parent / Guardian Information The person receiving service
Residential Address | Used only for internal communications and billing purposes
Payment Method How would you like to pay for services
Insurance Details | Please fill out accurate insurance details below
Insurance Card Upload
Upload front and back photos of your insurance card
Upload a copy of diagnosis documents & records
If you are unable to upload one or more documents, please check this box and we will get in touch with you to obtain the information.
By clicking this box you are giving Thrive Therapy permission to use or disclose your protected health information (PHI) for treatment, payment and health care operations purposes.
Drivers License Upload
Upload front and back photos of your drivers license
Start by filling out our online insurance verification form. If you encounter difficulty, please contact us at (214) 736-8376 Ext.101
IMPORTANT: Be prepared to upload front and back copies of your drivers license and insurance card.