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Getting Started

Start the electronic intake process by filling out the form below. With this process, you'll receive digital forms that you can complete whenever it's convenient for you.

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​This form is to establish routine care or services. Modern M.O.j.O. does not provide 24-hour on-call or emergency services. Visits are by appointment only. If you have an urgent need or emergency need for mental health assistance, please call the Suicide & Crisis Lifeline at 988, call your local emergency services at 911, and/or go to the nearest emergency department. 

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If you're unable to fill out the electronic forms online, please contact us by phone or email, and we can provide you with paper versions of the intake forms.

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Phone: 218-999-7750

Email: modernmojospecialist@gmail.com

Image by Pawel Czerwinski

Start Your Journey

This online service request is intended to be completed by the client directly, or by a parent or guardian on behalf of their children or dependents.

If you are a caregiver, facility representative, county worker, case manager, or any other third party, please note that this form is not intended for requesting Mental Health Services from Modern MOjO on behalf of your client. To facilitate the setup process for your client in our system, kindly contact us via phone at 1-218-999-7750 or email at modernmojospecialist@gmail.com.

Please enter the last name of the client or person requesting mental health services in this box.

Please enter the first name of the client or person requesting mental health services in this box.

Date of Birth
Month
Day
Year

Please enter the birth date of the client or person requesting mental health services in this box.

This email address will be used to establish the client’s electronic health record and online portal access. For clients who are children or dependents, please provide the email address of the parent or guardian.

This phone number will be used as the contact phone number for us to set up appointments and discuss the client’s care. For clients who are children or dependents, please provide the email address of the parent or guardian.    

Is the Client a child or dependent?
No
Yes
What is the Client's preferred visit type?
Preferred Office Location
Clients Sex at Birth
Male
Female
What type of services are you interested in?
If you’re looking for Medication Management services, is there a specific Medication Manager you would like to see at Modern MOJO?
If you’re looking for Therapy services, is there a specific Therapist you would like to see at Modern MOJO?

“By clicking 'Submit', you agree to Modern MOjO’s Terms of Use and Privacy Policy. You consent to receive phone calls and SMS messages from Modern MOjO’s to provide updates and information regarding your business with Modern MOjO’s. Message frequency may vary. Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy”. 

contact

address

988 Suicide & Crisis Life Line

hours

Modern MOjO, LLC.

28 NW 4th Street

Suite A

Grand Rapids, MN 55744

Phone: 218-999-7750

Fax: 218-999-9461

Mon - Thurs: 8AM - 5PM

Fri - Sun: CLOSED

Modern MOjO, LLC.

1708 1st St South

Willmar, MN 56201

If an individual has a plan or intent to harm self or others, please take them to the emergency room or call 911 immediately.

Modern MOJO DOES NOT SHARE personal information with third parties for marketing/promotional purposes. 

All content © 2026 Modern MOjO, LLC

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