Apply Now Patient Portal
Apply Now Patient Portal

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New Patient Intake Form

Alquimedez Mental Health Counseling provides bilingual telehealth services in selected licensed states.

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Please Get Help Now

If you are in immediate danger or experiencing a mental health emergency, please contact emergency services right away. This form is not monitored for emergencies.

📞 988 Crisis Lifeline 🚨 911 Emergency

When you are safe and ready to schedule an appointment, please return and complete this form.

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Request Received!

Our intake team will review your request and contact you within one business day using your preferred contact method.

Submitting this form does not establish a provider-patient relationship and does not confirm an appointment.

Your reference number:

Safety & Eligibility
Three quick questions before we begin.
Please answer this question.
Please select your state.
Note: At this time, Alquimedez Mental Health Counseling provides telehealth services only in states where our providers are licensed. Our team may contact you with general administrative information, but clinical services may not be available in your state.
Please select one.
Contact Information
Your information will be handled according to our privacy practices and applicable HIPAA requirements.
First name is required.
Last name is required.
Date of birth is required.
Please enter a valid US phone number.
A valid email address is required.
Service Requested
Select the service that best fits your needs.
Please select a service.
Note: Our providers follow strict protocols for controlled substances. A full psychiatric evaluation is required before any prescription can be issued. Prescriptions are at the sole clinical discretion of the treating provider.

Important: Requesting a controlled medication does not guarantee that medication will be prescribed. A full evaluation, clinical appropriateness, state rules, prescription-monitoring review, and provider discretion apply.
Insurance / Payment
This helps our billing team verify coverage before your appointment.
Please select a payment type.
Insurance company name is required.
Member ID is required.
📷 Click to upload front and back of insurance card
Our billing team will contact you for any additional insurance details.
Self-Pay / Not Sure: Our team will discuss rates and payment options with you before your first appointment.
Government-Issued ID
We require a valid government-issued photo ID to verify your identity before your first appointment. This is kept securely on file and is never shared without your consent.
🪪 Click to upload your photo ID (front & back if needed)
Accepted: Driver's license, passport, or state ID  ·  JPG, PNG, or PDF  ·  Max 2 files  ·  Max 5MB each
Consents & Acknowledgements
Please review and confirm each item below.
Required Acknowledgements
This acknowledgement is required.
This acknowledgement is required.
HIPAA acknowledgement is required.
This acknowledgement is required.
This acknowledgement is required.
This acknowledgement is required.
Automated & AI-Assisted Communications
Some intake communications may be assisted by automated systems or AI-supported tools for scheduling, routing, and administrative coordination. Clinical decisions are made only by licensed professionals.
Communication Preferences
Based on your preferred contact method, please confirm your consent below. Other methods are optional.
SMS consent is required based on your selected contact method.
WhatsApp consent is required based on your selected contact method.
Email consent is required based on your selected contact method.
Voicemail consent is required based on your selected contact method.
Review & Submit
Please review your information before submitting. You can go back to make changes.
What happens next? Our intake team will review your submission and contact you within one business day using your preferred contact method.

Submitting this form does not establish a provider-patient relationship and does not confirm an appointment.