Request an Appointment
This form may not be completed by minors (under 18 years old). If the patient is under age 18, a parent or legal guardian may complete the form for their minor children.
Adults (over 18 years old) may not complete the form for any other adults, unless the completer of the form has power of attorney or legal medical guardianship for the adult.
After you submit this form, the SLBMI Intake Department will contact you within a few business days. You may also email the SLBMI Intake Department at [email protected]. To respect your privacy, the Intake Department will try to reach you no more than two times without response.
We accept most major insurance companies, but we do not accept Medicaid Primary and Ambetter.
If at any time you feel you need immediate and critical assistance, please present yourself to the nearest Emergency Department, call the Crisis Hotline (Behavioral Health Response: 314-469-6644 or Provident St. Louis 24-hour Crisis Line: 314-647-4357) or call 911. Please do not wait for a return call from the intake specialists if you are in need of immediate and critical assistance.
Please note that all fields marked with an asterisk (*) are required.