Intake Form | The Alchemy Institute

What is your full name?

What is your email address?

What is your 10 digit phone number?

Where do you live (City and State)?

What is your date of birth?

How old are you?

What issues are you seeking help around?

What are your goals for treatment?

What psychiatric medication are you currently taking? If not currently taking psychiatric medication write 'none'

Are you on any controlled substance medications (e.g., Xanax, Klonopin, Valium, Ativan, Pain Pills, Ambien, Ritalin, Vyvanse)?

Yes

No

If so, please list any controlled substance and their respective doses.

Have you been psychiatrically hospitalized?

Yes

No

If so, where/when was the hospitalization?

Do you have any history of suicide attempt?

Yes

No

Maybe

If so, when?

Are you currently in mental health treatment or psychotherapy?

Yes

No

Do you have a preferred provider? If so, whom?

Aiereal Lloyd, PMHNP

Tabitha Bowman, PMHNP

No Preference

Who referred you to me or how did you find me?

Referral can be a friend, provider, google, facebook, etc.

Address