Melmed Center
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*Please e-mail forms to contact.us@melmedcenter.com or fax them to 480-443-4018*
​

***ALL TELEMED APPOINTMENTS NEED TO FILL OUT A CONSENT AND RETURN TO US VIA E-MAIL***
Telehealth Consent Form
File Size: 148 kb
File Type: pdf
Download File

Follow-up Patient Forms:

Child Follow-up Form
File Size: 219 kb
File Type: pdf
Download File

Adult Follow-Up Form
File Size: 162 kb
File Type: pdf
Download File

New or Re-Evaluation Patient Packets:

Our goal is to provide you with great care and service. These packets are an IMPORTANT part of our patient registration process. 
Please print, thoroughly complete, sign, and bring with you to your appointment.
New Patient Child Packet
File Size: 930 kb
File Type: pdf
Download File

Includes:
  • Did you know
  • Map
  • Child Registration Form
  • Consent for Purposes of Treatment, and Health Care Operations
  • The Academic Behavior Checklist (ABC) (5-17 years only)
New Patient Adult Packet
File Size: 892 kb
File Type: pdf
Download File

Includes:
  • Did you know
  • Map
  • Adult Registration Form
  • Consent for Purposes of Treatment, and Health Care Operations
  • Adult Intake Questionnaire
**We ask all established patients to please print the follow-up forms, thoroughly complete and bring with you to your appointment and make sure to arrive 10 minutes prior to your scheduled appointment.**

Changes/Updates:

If you have a change of address, please complete a Address Change Form, and e-mail it in as soon as possible.
Child Registration Form
File Size: 131 kb
File Type: pdf
Download File

Address Change Form
File Size: 50 kb
File Type: pdf
Download File

Adult Registration Form
File Size: 104 kb
File Type: pdf
Download File

If you have new insurance plan, please complete a Billing Update Form, and e-mail it in as soon as possible.
Billing Update Form
File Size: 75 kb
File Type: pdf
Download File

If you have a New Primary Care Physician, please complete a HIPAA Consent for Treatment, and bring to your appointment
Child HIPAA Consent for Treatment
File Size: 97 kb
File Type: pdf
Download File

Adult HIPAA Consent for Treatment
File Size: 102 kb
File Type: pdf
Download File

Mood Tracking Forms for Children

Mood Symptom Tracking
File Size: 76 kb
File Type: pdf
Download File

Adolescent Self Report
File Size: 79 kb
File Type: pdf
Download File

Symptom Tracking Parent
File Size: 81 kb
File Type: pdf
Download File

   

Mood Tracking Forms for Adults

Mood Symptom Tracking
File Size: 66 kb
File Type: pdf
Download File

Self Report
File Size: 79 kb
File Type: pdf
Download File

Psychology Forms

Counseling Treatment Consent
File Size: 98 kb
File Type: pdf
Download File

Non-Diagnostic Screening Consent
File Size: 90 kb
File Type: pdf
Download File

Psychology Assessment Consent
File Size: 88 kb
File Type: pdf
Download File

Teacher Forms

Clinical Attention Problem Scale
File Size: 73 kb
File Type: pdf
Download File

Academic Behavior Checklist
File Size: 114 kb
File Type: pdf
Download File

Classroom Observation Vanderbuilt
File Size: 119 kb
File Type: pdf
Download File

Consent Forms

Authorization for Release
File Size: 94 kb
File Type: pdf
Download File

Accompanying Adult Consent
File Size: 70 kb
File Type: pdf
Download File

Revocation of Authorization
File Size: 80 kb
File Type: pdf
Download File

Medication Consent
File Size: 716 kb
File Type: docx
Download File

Limited Consent For Treatment of a Minor
File Size: 71 kb
File Type: pdf
Download File

Request for Restrictions
File Size: 92 kb
File Type: pdf
Download File

Revocation of HIPAA Restriction
File Size: 72 kb
File Type: pdf
Download File

Individual Patient Forms (If Applicable)

Request for Letter
File Size: 72 kb
File Type: pdf
Download File

Privacy Policy
File Size: 79 kb
File Type: pdf
Download File

Prescription Benefits
File Size: 70 kb
File Type: pdf
Download File

   
Occupational Therapy Referral Form
File Size: 74 kb
File Type: pdf
Download File

Nutrition Packet
File Size: 733 kb
File Type: pdf
Download File

   
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