Patient Forms 

Please DO NOT email new patient packets! Print, complete, sign, and bring forms with you to your appointment!

The following are important forms.  Click on the name of the form to access the file.

To make initial contact with our intake coordinator for clinical services, please print out and complete the following Intake Registration Form. 

• New Patient Intake

Once completed, fax it to (480) 443 4018 or email to contact.us@melmedcenter.com. The admissions coordinator will contact you by phone to schedule the appointment within 48 business hours upon receipt.  

New or Reevaluation Patient Packets:

• New Patient Child Packet 

Includes:	Did you know
	Map
	Child Registration Form
	Consent for Purposes of Treatment, and Health Care Operations
	The Academic Behavior Checklist (ABC) (5-18 yrs only)

• New Patient Adult Packet

Includes:	Did you know
	Map
	Adult Registration Form
	Consent for Purposes of Treatment, and Health Care Operations
	Adult Intake Questionnaire

•  New Patient Child Psychological Services Packet 

Includes:	Did you know
	Map
	Child Registration Form
	Consent for Purposes of Treatment, and Health Care Operations
	The Academic Behavior Checklist (ABC)

• New Patient Adult Psychological Services Packet 

Includes:	Did you know
	Map
	Child Registration Form
	Consent for Purposes of Treatment, and Health Care Operations
	Initial Care Planning

Follow-up Patient Packets: 

• Follow-up Child Form
• Follow-up Adult Form

Mood Tracking Forms for Children:

• Mood Symptom Tracking Form
• Symptom Tracking Parent Form
• Clinical Attention Problem Scale Form
• Adolescent Self Report Form
• Classroom Observation Vanderbuilt Form

Mood Tracking Forms for Adults:

• Mood Symptom Tracking Form
• Self Report Adult Form

Individual Patient Forms (If Applicable): 

• Occupational Therapy Referral 
• Adult Registration Form 
• Child Registration Form
• Forma de Registro/Spanish Registration Form
• Authorization to Release Health Information Form
• Billing Update Form
• Privacy Policy 
• Nutritional Health Assessment  

Consent Forms 

• HIPAA Consent Form  
• Parental Treatment Consent Form
• Accompanying Adult Consent Form 
• Consent Revocation
• Limited Consent for Treatment of a Minor
• Animal-Assisted Therapy Consent Form
• Acupuncture Consent Form
• Request for Restriction Form
• Revocation of Authorization Form 
• Revocation of HIPAA Restriction Form

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