Name *

First Name

Last Name

Phone *

(###)

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Services

(please check all that apply)

Cognitive-behavioral therapy for anxiety issues

Talk therapy topics, i.e. difficulties and stuck points

Diagnostic consultation/second opinion

A mix of above

Clinical supervision (licensed professionals only)

*

I acknowledge that email and messages should not contain sensitive information, and that Dr. Melamed can’t guarantee the security of digital technology.

*

I understand that Dr. Melamed’s practice is out of network for insurance. Fees are paid by a credit card on file, and the practice provides a monthly statement for insurance purposes.

*

I acknowledge that this portal is not for psychiatric emergencies, which are directed to the nearest hospital emergency room.