Thrive Screening

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This screening will not be read immediately and may take up to two business days for a response. It is not intended to communicate emergency safety concerns. If you are unsafe or in an emergency, please contact 911 or proceed to your nearest emergency room. If you are in Washtenaw County and this is a mental health crisis, another resource is to call the county Crisis Team at 734-544-3050. Additionally, JFS is not licensed to provide substance use therapy.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Permission for Thrive Staff to leave a detailed voicemail?*

YesNoOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Referred by/Source
Date of Birth*

MonthDayYear
Date
Marital Status*
Gender*
Demographics

The following questions are for reporting purposes only and in no way impact eligibility for programs. Jewish Family Services provides services for all residents of Washtenaw County. We are committed to providing affordable, accessible, holistically-oriented and culturally sensitive care to our clients, whatever their identification, affiliation, lifestyle, background, race, religious creed, or national origin.
Less than $10,000$11,000-$25,000$26,000-$50,000$51,000-$75,000$76,000-$100,000More than $100,000
Religious Affiliation *
Race*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Relation

Over the past 2 weeks, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things ?*

0- Not at all1- Several days2- More than half of the days3- Nearly every day
Over the past 2 weeks, how often have you been bothered by any of the following problems: Feel down, depressed or hopeless ?*

0- Not at all1- Several days2- More than half of the days3- Nearly every day

Do you currently have insurance coverage?*

YesNo

Insurance Company Name*
Subscriber Name*

First NameLast Name
Contract or Recipient ID Number*
Group Policy Number*
Effective Date

MonthDayYear
Date
Do You Have Secondary Insurance?*

YesNo

Insurance Company Name*
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Contract or Recipient ID Number*
Group Policy Number*
Effective Date

MonthDayYear
Date

Thrive is unable to provide substance abuse treatment.

Please go to samhsa.gov, findtreatment.gov, or call 1-800-662-HELP (4357) to find resources.

What days and times are you available for appointments?
When is the best time and way to reach you?*
Please be aware that JFS is not open 24 hours, hours of operation are Monday-Thursday 9am-5pm, Fridays 9am-3pm and is closed on holidays. All requests will be responded to on the next business day. If you are feeling unsafe, thinking of harming yourself or others please call 911 or head to your local emergency department.

Additional crisis resources include: Washtenaw County Crisis Line (734) 544-3050, Crisis text number (text “HOME” to 741741), Psychiatric Emergency Services (734) 936-5900.
Should be Empty:

Demographics

Thrive is unable to provide substance abuse treatment.