AFMMH Need a Little More Support — Clinical Referral Navigation

Need a Little More Support? AFMMH helps you locate outside licensed mental-health or healthcare providers and community resources. AFMMH does not itself provide diagnosis, therapy, psychiatric care, or clinical treatment through this form. Provider availability, eligibility and acceptance are determined by the outside provider. Do not enter your medical history, diagnosis, or other sensitive details. This is not an urgent response service: call 911 for immediate danger or 988 for mental-health crisis support.

First name

Email address or phone number for follow-up

What kind of outside support would help?

City or county where you need services (optional)

Who is the referral for?

How would you prefer AFMMH to contact you?

How did you learn about AFMMH?

I understand AFMMH provides referral navigation, not clinical treatment. I consent to AFMMH contacting me about this request; details will not be shared with an outside provider without my further permission.

First name

Email address or phone number for follow-up

What kind of outside support would help?

City or county where you need services (optional)

Who is the referral for?

How would you prefer AFMMH to contact you?

How did you learn about AFMMH?