MIU Center | Mental Health Center | Intake Form

In-take Form

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

*In-person appointments are required for new patients.

Name

First Name

Last Name

Date Of Birth (MM/DD/YYYY)

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?

Have you had any suicide attempts in the past? If so, when was the most recent attempt and did you receive treatment for it?

How did hear about us?