Child Information Form

Child Information Form

  • Consent to Treatment/Agreement to Pay I do hereby consent to treatment with Michael J. Brown, MSC, LMFT. I have not been given any guarantees in regard to treatment. I may terminate my treatment at any time, but I will still be responsible for payment for services received.
  • I agree to pay Michael J. Brown for all services rendered at the time services are provided. I agree to a 48-hour cancellation notice or I will be charged for a missed appointment.

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