Intake Form

Thank you for choosing MIU Center. Please fill in the details below and we will reach out after your form has been reviewed.

*In-person appointments are required for new patients.

First name

Last name

Birthday

Month

Day

Year

Phone

Are you filling out this form for:

Name of your insurance? If you have none, state N/A

Do you use any illicit drugs or alcohol currently?

Have you been admitted to the hospital in the past 3 months? If yes, how many times

Do you have any suicidal thoughts or thoughts of self-harm?

Do you have any thoughts of wanting to harm others?

Is this appointment for FMLA paperwork?

FMLA paperwork is only completed after the patient has been with the practice for at least 90 days. Additionally, we do not complete long-term disability forms.

How did you hear about us?