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Mental Health Assessment Form

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    REASONS FOR THE CLINICAL APPOINTMENT: (THERE ARE A NUMBER OF SYMPTOMS THAT YOU MIGHT BENEFIT FROM VISITING A BEHAVIORAL HEALTH CONSULTANT.


    You can opt-out of receiving SMS updates or appointment reminders at any time. To stop receiving messages, reply STOP.

    Notice Regarding Communications from Alquimedez Mental Health Counseling

    We are a medical practice that provides telehealth medical care only. By checking the box below, you consent to receive text messages and emails with information about our medical practice from our electronic platforms.

    For more information, please refer to our privacy policy: Privacy Policy
    * I agree to receive text messages and emails from Alquimedez Mental Health Counseling.

    Telemedicine Consultation and Prescription Policy

    At Alquimedez Mental Health Counseling, our telemedicine consultants and medication prescribers strictly adhere to the rules and policies of the Drug Enforcement Agency (DEA). To ensure the highest standard of care, we require:

    1. Recent Physical Evaluation: You must provide a physical evaluation issued within the past year prior to your initial consultation.

    2. Referral from Primary Care Physician (PCP): A referral from your primary care physician (PCP) is required for telemedicine services with our practice within 30 days of initiating care.

    * By checking the box, you AGREE to our standard of care.
    By meeting these requirements, you play a crucial role in helping us maintain best practices and provide safe, effective care to all our patients.

    Consent and Agreement for Telehealth Services

    Alquimedez Mental Health Counseling uses third-party digital technology to support our patients' care.

    By clicking "Complete Submit" below, I confirm that I have read, understand, and accept the Disclaimer and the Privacy and Terms of Service. I also agree that Alquimedez Mental Health Counseling, PLLC is authorized to charge me or my health insurance for all fees due during the healthcare term.

    * I certify that I am authorized to sign and enter into this binding legal contract on behalf of the company or organization providing me with services.