Therapy Interest Form

Alchemy Therapy Interest Form
Therapists at Alchemy offer 50min weekly sessions with clients seeking ongoing talk therapy, either virtually or in-person at our office in Oakland. We ask that clients meet with their therapist weekly at a set day and time. This helps you save space every week to focus on yourself and gives you an opportunity to build momentum with what you’re working on.

We work as a sliding scale clinic, with services ranging from $60-$300 per weekly session. If you're hoping to work with a therapist at Alchemy, please fill out the form below. One of our therapists will reach out to you as soon as there's an opening. Please keep in mind that it can sometimes take several months to hear back if all therapists' slots are full.
- Note: The only psychedelic-assisted therapy currently available is ketamine-assisted therapy. Other legal psychedelics therapies are still only available through clinical trials (clinicaltrials.gov).
- If you are having a psychological crisis, please call Crisis Support Services of Alameda County at 1-800-309-2131 or the National Suicide Prevention Lifeline at 988.
- If you're looking for other sliding-scale therapy resources, check out our list here.
If you have any questions, please reach out to info@alchemytherapy.org
I am looking for:*
Please fill out this form if you're interested in ketamine assisted therapy. Thank you!
Please fill out this form if you're interested in couples/relationship therapy. Thank you!

Contact Info
Name*

First NameLast Name
Gender Pronoun(s)*

she/hershe/theyhe/himhe/theythey/themany pronounsno pronounsOther
Birthday*

MonthDayYear
Date
Birthday

MonthDayYear
Date

MonthDayYear
Date
Email
If you give us consent to email you
Phone Number
If you give us consent to call you
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Due to licensing laws, unfortunately we are only able to provide services to California residents.

If you live outside of California, here are some resource lists that may help you find support near you:
- Inclusive Therapists
- Open Path Collective
- KRIYA Ketamine Providers
- MAPS Psychedelic Integration
- Psychable
- Psychedelic.Support

Income
How much is your annual household income?*
$ before taxes you receive each year
Do you have Medicare? (Please note: we do *NOT* accept Medicare)
We also only have a few practitioners signed up with Carelon (not Medicare), but no current openings. For other insurances, we can send superbills if you need them.
How much is your annual household income? [number element, hidden]
How many dependents do you have?*
People who fully depend on you for financial support
Your income range falls in the upper range of Oakland residents. Given this, we encourage you to pay on the upper end of our sliding scale, $250-300. Please select how much you can pay below within that range.
Cost in USD for each 50min therapy session

Sliding Scale Tool
Alchemy works as a sliding-scale clinic, a tool built to help repond to historic and present-day systemic imbalance of wealth in many marginalized communities. By creating a range of rates, we are able to support our mission of equitable access to mental health services for diverse populations.

We've built the tool below to help you calculate where you land on our scale. Although we recognize financial security cannot be distilled to a series of questions, we hope this can be used as a good starting point to reflect on your resources and what you're able to contribute. We appreciate your transparency and honesty through this process.
Please check the following boxes for each question if your answer is "yes" to any of the statements. This will help to determine your sliding scale range.*

Do you currently own residential property or have access to stable rent-free housing? (This question does not apply to those who are Native or Indigenous)Have you earned a graduate degree?Are you able to make minimum payments on bills or credit cards?Do you receive healthcare coverage and benefits that allow you to afford and access necessary care?Do you have zero debt?Do you have a safety net of people in your life you can rely on for financial support if needed?Does your income only support you, and not other loved ones?Have you or do you expect to inherit a significant amount of money or property?None of the above
Is there anything else you'd like to share about your answers above?
Rate Structure Determination

Sliding Scale Payment
Recommended Sliding Scale
Calculated based on your answers above
Given the recommended range above, how much are you able to pay per session?*
Cost in USD for each 50min therapy session

Mental Health History
Have you ever attempted suicide or been hospitalized for psychiatric reasons?*
Since Alchemy employs many therapists in training, there may be times where we provide referrals out of our organization if it becomes clear that more comprehensive support is needed.
Please share some more details, including when and for how long.
If you prefer to discuss this more on your intake call instead of typing it out, please make a note of that. We understand it can be difficult to share this information.
Have you received a mental health diagnosis before?*
If you have a received a mental health diagnosis, what was it, and do you agree with it?
Are you seeking to change your relationship to drugs (including alcohol) or to any behavior you can't seem to control?*
Please share as much as you'd like about what kind of change you're hoping to make with drug use or behavior you can't seem to control.
This will help us find a therapist or referral that may be a good fit for your needs.
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Alchemy Therapy Interest Form

Contact Info

Income

Sliding Scale Tool

Sliding Scale Payment

Demographic Info

Therapy Info

Mental Health History