New Patient Intake | Mental Health Care

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Intake Form

Thank you for choosing MIU Center. Please fill out the form below, and we will get back to you shortly.

First name (If you are filling the form for someone else, please write their name below)*

Last name*

Birthday*

Month

Day

Year

Email address*

Phone number*

Are you filling out this form for:*

What is this appointment for?*

Insurance carrier*

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

Yes

No

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

Yes

No

Do you have any thoughts of wanting to harm others?:*

Yes

No

Do you use any illicit drugs or alcohol currently?:*

Yes

No

Is this appointment for FMLA paperwork?:*

Yes

No

How did you hear about us?:*

Message (optional)

HIPAA secure· 1 business day reply· Appointments Only

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