Ellen Dye, Ph.D - Informed Consent

INFORMED CONSENT
I have reviewed the Informed Consent For Treatment information and have discussed with Ellen Dye, Ph.D. any questions or concerns I have about her policies.

I agree to abide by the terms outlined in the Informed Consent for Treatment packet during my professional relationship with Dr. Dye.

I take full responsibility to pay for all services rendered by Dr. Dye including any legal testimony and outside consultations relating to Dr. Dye's work with me, my child, or the client I am financially responsible for.
Client Name *

First Name Last Name
Client/Parent/Guardian Signature *

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Date

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Date
Financially Responsible Party Signature (if different from above)

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Date

Month Day Year
Date
Please verify that you are human *
6325 Executive Boulevard | Rockville, MD 20852 | Telephone (301) 770-0275 | Fax (301) 770-0276
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INFORMED CONSENT