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Consultation or Referral

Fill out this form if you would like to speak personally with a MIP member about a consultation or referral.

Please note that MIP is not an emergency service and it may take us a few days to respond. If you need immediate help, please call 1-800-985-5990 or text TalkWithUs to 66746 to connect with a trained crisis counselor.

Referral Form

Name(Required)
This is optional, but by providing your insurance information will enable us to help you find a better match (i.e., someone who takes your insurance).