THERAPYAPPOINTMENT Please enable JavaScript in your browser to complete this form.For Emergency - Step 1 of 8If you are in crisis, please call the 24/6 crisis helpline 808-832-3100 / toll-free 800-753-6879 or call 911.NextWelcome to THRIVE Kauai We gather basic referral information to better serve you. This information will be kept confidential and is viewed by THRIVE Kauai staff only.PreviousNextPrimary InsuranceHMSAHMSA QuestHMAAHMAUHAKaiserSecondary InsuranceHMSAHMSA QuestHMAAHMAUHAKaiserPreviousNextWhen are you available?DaysMondayTuesdayWednesdayThursdayChoose all available days.Time of DayMornings 9am-12pmAfternoons 12pm-4pmChoose all available times.Location PreferenceOnlineIn-PersonPreviousNextAre services being sought for situations requiring documentation for third parties (i.e. work leave, disability determination, job readiness, legal proceedings)?Documentation for Third Parties *Select oneYesNoMaybeUnfortunately, we are unable to provide documentation services for the following: legal-related issues (i.e. child custody evaluations), disability determination, work readiness assessment, work leave, worker’s comp evaluation PreviousNextNew or Returning ClientNew ClientReturning ClientName of Client *FirstLastLayoutClient's Date of BirthClient's Age*Please note that testing is available for ages 6 and above, psychotherapy is available for ages 10 and above, and educational services are available for ages 5-16.Client's School and Grade (if minor)PreviousNextName of Contact *FirstLastRelationship to ClientSelfChildOtherPlease describe your relationship to the client.LayoutContact PhoneContact Email *Which of the following is acceptable and preferred for leaving messages:PhoneEmailTextAll of the abovePreviousNextReason for AppointmentPsychotherapyEducational ServicesAssessmentEducational Consultation/Case ReviewReferred By:Has the client been referred for any of the following reasons:AnxietyDepressionSituational StressSubstance AbuseSelf-harmSuicidal ThoughtsTraumaGrief/LossBehavioral IssuesLearning DifferencesOtherCheck all that apply.Describe the reason:Optional: Brief description of general concerns, additional comments, or questionsPreviousSubmit