Adult Information Form - Happy Couples Healthy Communities

Adult Information Form

Michael J. Brown, MSC, LMFT

Happy Couples Healthy Communities

Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Date of Birth
MM slash DD slash YYYY
Soc. Sec. #*
Gender
Employed by:
Occupation:
Referral from:
Marital Status:
What would you like to accomplish from your time in therapy?
Signature

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.