Member Intake

Intake Questions

* Indicates required field

Name *

First

Last

Email *

Do you have any expectations of the program? If so waht are they? *

I hope to achieve the following goals within the next year *

What do you think would help you acieve these goals? *

Please provide your email used for FACEBOOK so we can send an invite to our private community *

I understant that in order to receive assistance from any of the programs offered by AMHH, I must meet the following requirements *

Be living a single lifestyle with no significant other in the home Live in Lee County Have children under 18 at home Must attend at least 2 support group meetings per quarter

By typing your name below, you agree to the above requirements *

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