There Are 4 Sections to This Form

Section One
Name *
Name
Phone *
Phone
Address *
Address
Date of Birth *
Date of Birth
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number
Section 2
Seeking Treatment For: *
Have You Had Thoughts of Suicide
Have You Been Hospitalized in an Inpatient Psychatric Unit?
Section 3
Authorization for Release of Health Information
Name of Doctor/Therapist
Doctor/Therapist Address *
Doctor/Therapist Address
Doctor/Therapist Office Phone *
Doctor/Therapist Office Phone
Doctor/Therapist FaX
Doctor/Therapist FaX
To Relase my Information to:
Midwest Institute for Hearts and Minds (314) 270-4248