Personal Information Form

Patient Name: _________________________________________________DOB: __________________

Referred by/ Where Did You Hear about Dr. Elise: _________________________________________________

Address: _____________________________________________________________________________

____________________________________________________________________________

Phone: (home) _____________________________ Primary Care Physician: _________________

(cell) _____________________________ ___________________________________

(work) _____________________________ ___________________________________

E-mail: ______________________________________

Would you like to receive our quarterly newsletter? Y N

For patients younger than 18 years of age, please complete the following:

Father: ______________________________________________________________________________

Address: _____________________________________________________________________________

______________________________________________________________________________

Phone: (home) _____________________________

(cell) _____________________________

(work) _____________________________

Mother: ______________________________________________________________________________

Address: _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Phone: (home) _____________________________

(cell) _____________________________

(work) _____________________________

Financial Agreement

I understand that payment is expected at the time of service. A fee of $25 will be assessed for any returned checks. I understand that I will be responsible for full payment if I do not give 24 hours notice of cancellation or change of appointment. I understand that my insurance company will not be responsible for this payment. I also understand that failure to maintain responsibility for payment may result in my account being sent to an independent agency for collection. I consent to the release of information for this purpose, and I agree to pay any costs associated with such collection. I authorize Elise G. Abromson, Psy.D.,LLC to release any medical or mental health information necessary to help me process insurance claims.

__________________________________________________ _____________________

Patient/Parent/Guardian Date