Name *

First Name

Last Name

Phone *

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Date of Birth *

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DD

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Practice Policies

I understand that: • Email/messages are not a secure method of communication, so Dr. Melamed cannot guarantee the privacy of these messages; • Dr. Melamed does not maintain constant email or text monitoring, so there may be a delay in responding; • Email & text communications are part of my medical record; and I agree not to use email for communications of a personal, time-sensitive, or emergency nature. Risks/Benefits of Treatment: • I understand that there are risks and benefits to both psychotherapy and medication treatment, as well as using Telehealth, and I consent to treatment.

I Understand & Agree