Mental Health Intake FormPlease call 911 if your life is in danger or you need immediate Psychiatric evaluation. Name * First Name Last Name Date of Birth Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Insurance Type Insurance Number Do you have additional Insurance? If Yes, please email a copy of your insurance to intake@ahtic.org. Language spoken at home Services Needed Type of Visit In Person Telehealth (virtual) Your availability for an in-person intake appointment Thank you!
