Contact | Thrive Wellness Reno

Thank you for considering Thrive Wellness as a trusted partner in providing your patient with a higher level of care.

Please complete the following admissions form to refer your patient. The information you submit is secure and confidential and is intended to provide our admissions team with adequate information to begin the intake process. A member of our team will be in touch with you to confirm receipt of referral and to collect any additional information needed to obtain a comprehensive understanding of your patient’s condition as well as to begin the process of recommending a course of care and developing an individualized treatment plan.

We look forward to working with you and helping your patient achieve lasting recovery.

Quick Admission Form

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Patient Information

First Name

Last Name

Date of Birth

Phone Number

Seeking Level of Care

Race

Relationship Status

Religion/Spiritual Orientation

Disablities

Employment Status

Highest Education

Military Service

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Guardian Information

First Name

Last Name

Phone Number

Relationship to Patient

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Insurance Information

Name of Insurer

Insurance Contact Phone

ID/Account Number

Group Number/Account Number

Name of Policy Holder

Relationship to Patient

Policyholder Date of Birth

Name of Employer

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Treatment Team Information

Therapist Name

Dietitian

Psychiatrist

Primary Care Physician

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Provider Assessment

Height

Weight

Diagnosis

Diagnosis Notes

Treatment History

Other Medical Issues

Current Medications

Known Food Allergies

Known Medication Allergies

Patient Strengths

Preliminary Treatment Goals

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Submitting Provider Information

First Name

Last Name

Phone

Employer/Organization

How did you hear about us?

Refer Your Patient to a Higher Level of Care

Quick Admission Form