MelrosePsych Forms

For your convenience, you may now complete the MelrosePsych Initial Appointment Packet entirely online using our secure, encrypted digital signing system. You will be mailed the link to the online packet once you book an appointment. Once you fill out the form and sign, you will be emailed a saved PDF file of the agreement for your records, and Dr. Baltz will be notified.

If you are having problems with focus, memory, or sustaining attention, please download and complete the optional ASRS form below.

Required Forms – Downloads

Initial Intake Form

MelrosePsych Initial Appointment Packet

New patients can save time by filling out the Initial Appointment Packet using our convenient, secure online system. You will receive a link when you book your appointment. Once you sign, you will be emailed a copy for your records and Dr. Baltz will be notified.

If you are having technical problems, you may download the form here. The form must first be saved to your device before filling it in.

Optional Forms

Adult ADHD Self Report Scale

ASRS (Adult ADHD Self Report Scale)

For clients with problems sustaining focus and completing tasks. The form must first be saved to your device before filling it in.

MelrosePsych
8060 Melrose Ave, Suite 200, Los Angeles, CA 90046
800 5th Ave, Suite 101-800, Seattle, WA 98104