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?

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?

Do you have any active (or past) addiction to alcohol or drugs?

Yes

No

Are you willing to have records released from any previous mental treatment providers?

Yes

No

Are you currently in mental health treatment or psychotherapy?

Yes

No

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

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

Is it okay if we text you with appointment instructions?

Yes

No

How old are you?