Prefer to Write it Down?

Name *

First Name

Last Name

Potential Client Name

If different than person completing this form

First Name

Last Name

Potential Client Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Please Note *

At this time, we are unable to accept clients who are covered by Medicare, CCS, or Medicaid/BadgerCare. We sincerely apologize for any inconvenience this may cause and encourage you to reach out if you'd like assistance finding alternative resources.

No problem!

I have one of these; can you help me find a referral?

The Legal Stuff *

By submitting this form, I acknowledge and agree that I am not currently a client under the care of Modern Thrive Counseling (“the Practice”). I understand that submission of this form does not establish a therapeutic relationship or constitute the initiation of clinical services. I further acknowledge that Modern Thrive Counseling will make reasonable efforts to connect me with a suitable therapist in a timely manner. However, in the event that the Practice is unable to accommodate me or determine that my needs may be better served elsewhere, I understand that I may be provided with referrals to alternative providers who may be a more appropriate fit for my care.

I agree

I do not agree and I recognize this disqualifies me from being matched at Modern Thrive Counseling at this time.