Sign-up Online for Mental Healthcare

To make sure we match you with the right care team at AMFM Healthcare, we have a few questions to ask.

What to Expect During Sign-up

Signing Up for Myself

Estimated time needed: 10-15 minutes

We believe in treating the whole person. That’s why our intake asks for a bit more detail than others; including your insurance coverage and existing healthcare providers.

Your Insurance Card: So we can verify your benefits and copay immediately.
Current Provider Details: Contact info for your primary care doctor or current psychiatrist to ensure coordinated care.
Medical History: A general idea of current medications or past diagnoses.

Referring a Loved One

Estimated time needed: 3 minutes

Our goal is to help your loved one get the care they deserve. We will ask questions about your concerns for them, age and contact information, if they are over the age of 18.

Referring a Client or Patient

Estimated time needed: 5 minutes

Our goal is to help your client or patient get the mental health support needed. We will need contact information, referral details, and age information to ensure we can offer the best care.

"*" indicates required fields

1Get Started

8Background

18Finalize

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DKV_First

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DKV_Last

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BD-name

Are you seeking help for yourself, a loved one or a client?*

For myself

For a loved one

For a client

Are you suffering with any of the following mental health symptoms?*

I sometimes think people would be better off without me.

I’ve thought about hurting myself or someone else.

I worry a lot or feel constantly on edge.

It’s hard to trust people or I feel like others are against me.

I feel sad, lonely, or numb.

I’ve lost interest in things I used to enjoy.

It’s hard to find the energy to do things.

My mood changes quickly.

Sometimes I have too much energy or can’t slow down.

I’ve been sleeping too much or too little.

My eating habits have changed a lot.

I sometimes see or hear things others don’t.

Things around me sometimes feel unreal.

I get angry easily or take it out on myself or others.

I get stuck on certain thoughts.

I do certain things over and over to feel okay.

It’s hard to do daily things like showering or cleaning.

I’ve been drinking or using substances more than usual.

Something else has been hard for me lately.

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Mental Health Symptoms

I sometimes think people would be better off without me.

I’ve thought about hurting myself or someone else.

I worry a lot or feel constantly on edge.

It’s hard to trust people or I feel like others are against me.

I feel sad, lonely, or numb.

I’ve lost interest in things I used to enjoy.

It’s hard to find the energy to do things.

My mood changes quickly.

Sometimes I have too much energy or can’t slow down.

I’ve been sleeping too much or too little.

My eating habits have changed a lot.

I sometimes see or hear things others don’t.

Things around me sometimes feel unreal.

I get angry easily or take it out on myself or others.

I get stuck on certain thoughts.

I do certain things over and over to feel okay.

It’s hard to do daily things like showering or cleaning.

I’ve been drinking or using substances more than usual.

Something else has been hard for me lately.

To help us understand how we can help, which of the following signs or behaviors have you recently noticed in your loved one that are causing you concern?*

Mentions of being better off dead or hurting themselves

Threats or actions to hurt self or others

Non-stop worrying or extreme anxiety

Lack of motivation

Lack of interest in usual activities

Aggression toward self or others

Lack of joy or inability to experience pleasure

Paranoid thoughts, suspiciousness, or severe distrust

Delusional thoughts or hallucinations

Severe mood swings or mood dysregulation

Manic-like symptoms (e.g., not sleeping, rapid speech, lack of impulse control)

Significant changes in sleep (too much or too little)

Significant appetite changes or weight loss/gain

Obsessive thoughts or actions (compulsions)

Difficulty trusting others

Difficulty completing daily living tasks i.e. showering, brushing teeth

Increased or new use of alcohol or substances

Other

Referring Provider Information

Your First Name*

Your Last Name*

Your Phone Number*

Your Email

Consent

By checking this box, I agree to the terms of service and privacy policy and give my express written consent for AMFM Healthcare company to contact me at the number provided above, even if this number is a wireless number or if I am presently listed on a Do Not Call list. I understand that I may be contacted by telephone, email, text message or mail regarding my options and that I may be called using automatic dialing equipment. Message and data rates may apply. Consent to receive text messages is not a condition of purchase. Message frequency varies. Reply HELP for help. Reply STOP to unsubscribe.

I have read and consent to the terms listed above.

Your Direct Number*

Extension

Your Company or Agency*

Referrer Location*

City State ZIP Code

Reason for Referral*

Will this client be returning to your care?*

Will ongoing communication be needed?*

What is your relationship with your loved one?*

I am their....

Parent or Guardian

Child

Spouse or Significant Other

Sibling

Grandparent

Other

Is your loved one 18 years of age or older?*

Yes

Is your loved one aware you are reaching out on their behalf?*

Yes

Patient Information

We will reach out to you first before contacting your .
Our goal is to help you and them without causing undue stress.

Is the patient 18 years of age or older?*

Yes

Patient's Parent's or Guardian's Name*

Patient's Parent's or Guardian's Phone Number*

Loved One's First Name*

Loved One's Last Name*

Loved One's Phone Number*

Patient First Name*

Patient Last Name*

Patient Phone Number*

Patient Location*

State ZIP Code

Our team is dedicated to providing mental health care for patients ages 12-65.

Patient Date of Birth*

MM slash DD slash YYYY

Your Date of Birth*

MM slash DD slash YYYY

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Age for Myself

's Date of Birth*

MM slash DD slash YYYY

What gender does your client identify as?*

What pronouns does your client use?*

What gender does identify as?*

What pronouns does use?*

What gender do you identify as?*

What pronouns do you use?*

Client Insurance Provider (If known)

Client Insurance Member ID (If known)

Intended Level of Care*

Residential

Outpatient

Telehealth

Unsure

What state do you live in?*

State

What state does live in?*

State

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In State

✨ Your Treatment Preferences

Let's figure out your availability and the type of care you are looking for. If you are unsure about any of these options, that's okay - we're here to help and can discuss your options.

How many days a week are you interested in care?*

3 days a week

5 days a week

7 days a week

Unsure

What type or level of care are you interested in?*

What do you mean by level of care?

In-Person: This is traditional care where you physically go to a therapist's office or a clinic for your sessions.; Think of it like: Going to your regular doctor's office.; Best for: People who prefer face-to-face interaction, need hands-on therapies, or are dealing with a crisis that requires immediate, secure support.
Telehealth / Virtual: This is care you receive remotely using technology, usually through video calls (like Zoom), phone calls, or secure messaging.; Think of it like: A video chat with a friend or a work meeting, but with your mental health provider.; Best for: People who need convenience, have mobility issues, or live far from providers. Good for people that are comfortable using technology.
Hybrid In-Person / Virtual: This is a mix of both in-person and virtual care. Some appointments you attend in the office, and others you do remotely.; Think of it like: A flexible school schedule where you have some classes online and some face-to-face.; Best for: People who want the personal connection of in-person care but also need the flexibility and convenience of virtual appointments.
Residential: This is the most intensive level of mental health care, where you live one of our houses for a period of time (days, weeks, or months) to receive round-the-clock structure and support. It is usually for people with severe symptoms or who have not gotten better with less intensive treatment.; Think of it like: A live-in retreat or school where all your time is dedicated to getting better under professional supervision.; Best for: People who are struggling to function safely or manage their illness at home and need a safe, structured, therapeutic environment.
Unsure: This simply means you don't know yet what level of care is right for you. It's perfectly normal!; Your Next Step: You start by talking to our mental health intake specialist who can assess your needs and recommend the appropriate level of care.

In Person

Telehealth / Virtual

Hybrid In-Person / Virtual

Residential

Unsure

What schedule works best for you?*

Weekdays

Weekends

Morning

Afternoon

Evening

Flexible Schedule

Do you have a stable internet connection and computer or a smartphone that can do virtual meetings?*

Yes

✨ Experience with Treatment

This section focuses on your past experiences with therapy or other mental health treatments. We want to know what was tried, what was helpful, and what didn't work for you.

Have you ever been in an outpatient or residential mental health program (excluding 1-to-1 therapy)?*

Yes

This section allows you to enter multiple items of information using a flexible list.

Flexible List How To

List one item per row.
Click the "+" button to include as many entries as you need.
Use the "-" button to delete any unwanted rows.

if yes, please tell us about your previous treatment history.

Approximate Start Date

Type of Care

Provider or Company

Location

Is there anything you found particularly beneficial or enjoyable about your previous treatment?

This section allows you to enter multiple items of information (like medications, past employers, or addresses) using a flexible list.

We want to find the best fit for you, and your experience is important. Could you share why the previous program wasn't the right fit? Knowing your reasons will help us tailor a better solution moving forward.

📜 Background

This section asks questions about your general physical and mental health. This includes information on past illnesses, ongoing medical conditions, previous psychiatric diagnoses, and any significant life events that have affected your well-being.

Have you been hospitalized in the last 30 days?*

Yes

What type of hospital visit was it?*

For Psychiatric Reasons

For Physical or Medical Reasons

Was your visit voluntary or involuntary?*

Voluntary

Involuntary

Do you have any current diagnosis for any physical or mental health conditions?*

Yes

If yes, which if, if any, of the following conditions do you have a diagnosis for or have experienced?*

Anti Social Personality Disorder

Autism Spectrum Disorder

Autoimmune Disease

Endocrine or Hormonal Disorder(s)

Chronic Pain Condition

Dissociative Identity Disorder

Neurological Condition

Other Personality Disorder

Sleep Disorders

None of these apply

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Mental Health Conditions Diagnosis List

Anti Social Personality Disorder

Autism Spectrum Disorder

Autoimmune Disease

Endocrine or Hormonal Disorder(s)

Chronic Pain Condition

Dissociative Identity Disorder

Neurological Condition

Other Personality Disorder

Sleep Disorders

None of these apply

You indicated you have an Autism Spectrum Disorder Diagnosis (ASD). At what age were you diagnosed?*

Do you have any accommodation or support requirements related to ASD?*

Do you have a history of seizures?*

Yes

You indicated you have had seizures. When was your last seizure? Do you take any medication? If you have a neurologist, please share their name and contact info.*

Are you currently in care with a psychiatrist, psychologist, or therapist?*

Psychiatrist

Psychologist

Therapist

Your 's Full Name*

Your 's Phone Number*

Your 's Location*

City State

Please indicate if you currently have a condition that results in low or restricted function in any of the following areas:*

Sight (e.g., low vision or blindness)

Hearing (e.g., partial or total deafness)

Ambulation (e.g., difficulty walking or being confined to a wheelchair)

None of these apply

Are you currently taking any prescribed medication?*

Yes

If yes, are you prescribed any of the following medications?*

Any Controlled Substances (Schedule I-V)

Anxiety Medication

Depression Medication

Antipsychotics

Anticonvulsants or Anti-Seizure Medication

Cardiovascular Meds (Beta-Blockers, Statins)

Insulin or Metformin

Hormonal Medication (Corticosteroids, Hormonal Contraceptives, Thyroid Meds)

Medication Assisted Treatments (Disulfiram, Methadone, Buprenorphine, Suboxone)

Mood Stabilizers

Non-benzodiazepine Sleep Medication (Zolpidem, Ambien)

Stimulants

None of these apply

Are you currently (within the last 3 weeks) using any non-prescribed substances?*

This includes alcohol, non-prescribed medications, and illicit substances.

Yes

Please indicate which type of substances you have used in the last 3 weeks..*

Alcohol

Opioids/Narcotics (Heroin, Oxycodone, OxyContin, Fentanyl, Hydrocodone, Vicodin)

Benzodiazepines (Alprazolam, Xanax, Diazepam, Valium, Lorazepam, Ativan)

Non-benzodiazepine sleep medicines (Zolpidem, Ambien)

Cocaine (including Crack)

Methamphetamine (Meth, Crystal Meth)

Prescription Stimulants (Amphetamine, Dextroamphetamine, Adderall, Methylphenidate, Ritalin)

Synthetic Cathinones (Bath Salts)

Cannabis (Marijuana)

LSD (Acid)

Psilocybin (Magic Mushrooms)

MDMA (Ecstasy, Molly)

PCP (Angel Dust)

Ketamine

Dextromethorphan (DXM)

Inhalants (Glue, Aerosols, Paint thinner)

Other

Are you currently experiencing any withdrawal symptoms?*

Yes

Have you ever overdosed on any medication or substances?*

Yes

When did your last overdose occur?*

Within the last 5 days

Within the last year

Over a year ago

Do you have a history with eating disorders?*

Yes

Do you have an active eating disorder?*

Note: Over the last three weeks, would you say that thoughts about your weight, body shape, or food have dominated your life causing you significant distress, restricted eating, bingeing, purging, or excessive exercise.

Yes

Have you ever had a traumatic brain injury (TBI)?*

Yes

If yes, please provide details of your TBI.*

Have you ever put yourself or someone else in harm's way as a result of your mental health symptoms?*

Yes

Do you have active thoughts of harming yourself?*

Yes

If yes, please indicate which, if any apply toward harming yourself:*

I know why I want to harm myself

I have a plan to harm myself

I have the tools to harm myself

None of these apply

Do you have a history of suicide attempts or planning?*

Yes

How many suicide attempts have you had in your lifetime?*

Attempted in the last 5 days

Attempted at least once in the last year

More than 3 attempts in your lifetime

Only attempt over a year ago

Do you have active thoughts of harming others?*

Yes

If yes, please indicate which, if any apply toward harming others:*

I know why I want to harm others

I have a plan to harm others

I have the tools and/or access to harm others

None of these apply

What is your current living situation?*

I live alone.

I live with my family.

I have roommates.

I am homeless.

What type of relationships do you have in your life?*

I am single.

I am married or in a committed relationship.

I have adult children.

I have children under the age of 18.

You indicated you have children. What is their living situation*

My children live with me.

My children live with other family members.

My children are currently in care outside of the family.

My children are at school or live on their own.

Is your children's current living situation your preferred arrangement?*

Yes

I need to explore my options.

What other types relationships do you have in your life?*

I have family I am close with.

I have no contact with my family.

I have no remaining family.

I have friends I am close with.

I have no friends I am close with.

Other

What is your employment situation?*

Full Time Employment

Part Time Employment

Gig or Contract Work with Varied Hours

Own My Own Business

Unemployed

Underemployed

Stay at Home Parent or Caregiver

On Disability or Medical Leave

Retired

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Currently Employed

Full Time Employment

Part Time Employment

Gig or Contract Work with Varied Hours

Own My Own Business

Unemployed

Underemployed

Stay at Home Parent or Caregiver

On Disability or Medical Leave

Retired

Are you a military veteran or active service member?*

Yes

. thank you for your service! 👏

Do you have any history of trauma?*

Yes

What types of trauma have you experienced?*

Mental or Emotional

Physical

Sexual

Do you have any history of being sexually or financially exploited?*

Yes

Do you have any history of violent behavior?*

Yes

Do you have any current or past legal issues (Domestic Violence, Prior Arrests, DUI, Felonies, etc.)?*

Yes

Do you have any pending felony charges?*

Yes

Do you have a felony conviction related to violence, kidnapping, murder, aggravated assault or battery, or reckless endangerment?*

Yes

Please provide details of any pending legal issues.*

This includes but is not limited to: domestic cases, custody cases, criminal cases, civil cases. If nothing is pending, please put none.

Do you have a history of harming animals?*

Yes

Do you have any history of fire setting or arson?*

Yes

If yes, please explain your history of fire setting or arson.*

Do you have any history of sexually deviant behavior?*

Yes

If yes, please explain your history of sexually deviant behavior.*

Is there anything else you would like to share with us about your current mental health, medical conditions, or needs for support?

🏥 Paying for Treatment

Our mental healthcare programs are always tailored to meet your individual needs. Because of this, your unique treatment plan and the level of care you require will determine your exact costs. We will go over any out-of-pocket costs with you directly over the phone or in person. You have multiple options to pay for high-quality mental healthcare services.

Using Insurance for Care: The Affordable Care Act made mental health treatment an essential benefit. As a result, your insurance may cover all or part of your treatment. Your responsibilities will include any co-pay and/pr deductible while your insurance provider will cover the rest. We'll help you check this in the next step.

Financing Options: We believe everyone who needs help should be able to attend a mental healthcare program. Based on your situation, you may qualify for financing or other flexible payment options. We will discuss this option with you on the phone.

Self-Pay Options: We accept Checks, ACH, major cards, and some wallet or digital payment options to help you pay for your care.

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Do you have health insurance?*

Yes

🏥 Health Insurance Info

You can quickly and privately check your insurance benefits with us right now. We'll be able to tell you if your provider is in-network with our programs.

You can find the necessary information on your providers' online portal or on your insurance card.

Insurance Card Examples

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Who is your health insurance provider?*

What is your Member or Subscriber ID?*

This may be listed as member ID, subscriber ID, or just ID on your insurance card.

What is your group ID?

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VTX Verified Status

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VTX Verified Success

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VTX Payor Name

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VTX Error Code

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VTX Days Remaining

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VTX Coverage Type

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VTX Has Medicaid or Medicare

Sign-up Online for Mental Healthcare

What to Expect During Sign-up

Signing Up for Myself

Referring a Loved One

Referring a Client or Patient

Healing Begins Here