Client Information The person receiving service

Availability
Please describe the client's availability. Provide specific days and times.

Parent / Guardian Information The person receiving service

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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

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Insurance Card Upload
Upload front and back photos of your insurance card

Diagnosis Upload 
Upload a copy of diagnosis documents & records

Front Image
Max File Size 15MB
Back Image
Max File Size 15MB
Diagnosis / Report
Max File Size 15MB

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.

Front Image
Max File Size 15MB
Back Image
Max File Size 15MB

Drivers License Upload
Upload front and back photos of your drivers license

Insurance Verification

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. 

Services

(214) 736-8376

Ext. 101

2825 Valley View Ln #100,

Farmers Branch, TX 75234

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©2019 Thrive Therapy LLC