You are submitting a request for assessment by Dr. Melissa Jay Dr. Amélie Dubé . You MUST RESIDE in the states/provinces listed above for them to assess you. This information is being used by the practitioner, and only Dr. Melissa Jay Dr. Amélie Dubé , to review your request for an assessment. Once this form is completed, Dr. Melissa Jay Dr. Amélie Dubé is notified and will contact you about next steps.