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 * (###) ### #### SMS Privacy Terms * By checking this box, I consent to receive text messages from Agents of Hope Training & Information Center related to conversation purposes. You may reply STOP to opt-out at any time. For assistance reply HELP or visit www.ahtic.org. Messages and data rates may apply. Message frequency will vary. Learn more on our SMS Terms & Conditions, Privacy Policy, and Terms of Service page. 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!