Ellen Dye, Ph.D - Client Information Form

CLIENT INFORMATION FORM
CLIENT INFORMATION
Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Pronoun
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
Email Address
example@example.com
Occupation
Highest Level of Education
Marital Status
Partner's Name

First Name Last Name
Referred By
History of Previous Treatment
FINANCIALLY RESPONSIBLE PARTY'S INFORMATION

If different from the client
Name

First Name Last Name
Relation to Client
Email Address
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
For Child and Adolescent Clients
Name of School Attended
Grade Level
Siblings' Names and Ages
Parents' Marital Status

Married Divorced Separated Widowed
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number

Area Code Phone Number
Work Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Parent/Guardian 2 Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number

Area Code Phone Number
Work Number

Area Code Phone Number
Cell Number

Area Code Phone Number
AUTHORIZATION FOR TREATMENT
I have read Dr. Dye's Policy Statement and accept the terms as stated. I accept financial responsibility for services rendered. I authorize the office of Dr. Dye to release information to my insurance company as necessary.
Client/Parent/Guardian Signature *

Clear
Date

Month Day Year
Date
Financially Responsible Party Signature

Clear
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
Should be Empty:

CLIENT INFORMATION FORM

CLIENT INFORMATION

FINANCIALLY RESPONSIBLE PARTY'S INFORMATION

For Child and Adolescent Clients

PARENT/GUARDIAN INFORMATION

AUTHORIZATION FOR TREATMENT