Member Intake

Please fill out the form below. Once it is received, a zoom appointment will be scheduled based on your availability and our open appointments.

Intake Questions

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Meetings are scheduled in the evenings Monday - Friday at 6:30 pm or Saturday afternoons. Do you have a preference of day? *

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 achieve these goals? *

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

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

Submit