# Mental Health Assessment Form

- Link: https://www.alquimedez.com/mental-health-care-mental-health-assessment
- Published: 2024-09-15T17:01:47+00:00
- Author: alquimedezhemo

**Select Language**

  English

  Spanish

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

Choose Option*

Choose Sub Option*

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Referral Type:*

Therapy - Reason for Referral*

Medication Management - Reason for Referral*

First Name*

Last Name*

Date of Birth*

Mobile Number* 
 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](https://www.alquimedez.com/mental-health-care-privacypolicy)
*
I agree to receive text messages and emails from Alquimedez Mental Health Counseling.

Email*

Address*

Address line 2

City*

State / Province*

Postal / Zip Code*

### 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.

Insurance Name

Insurance Number

Name of Medical Doctor

Name of Medical Office

Telephone of Medical Office

Upload ID and Insurance Information

Upload Medical Records to Portal

### 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. Financial responsibility
is limited to amounts properly assigned to me under applicable law and my insurance
plan. An insurance denial does not automatically make the denied amount my responsibility.
Verification of benefits is not a guarantee of payment. Any required notice or separate
agreement for noncovered or out-of-network services will be obtained. This submission
does not authorize automatic card charges; card storage and charges require a separate
authorization. Please review the [Financial Responsibility Agreement](https://www.alquimedez.com/financial-responsibility-agreement).

* 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.

Where You Learned About Us (Alquimedez)

Date*

Signature*

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