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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.

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Therapy - Reason for Referral*

Medication Management - Reason for Referral*

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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
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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.

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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.

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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.

Notice Regarding Communications from Alquimedez Mental Health Counseling

Telemedicine Consultation and Prescription Policy

Consent and Agreement for Telehealth Services

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