Child Information Form - Happy Couples Healthy Communities

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age

Date of Birth*

Soc. Sec. #

Gender

Mother's Name

First Last

Mother's Age

Mother's Date of Birth

Mother's Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Home Phone

Mother's Cell Phone

Work Phone

Mother's Email

Mother's Occupation:

Father's Name

First Last

Father's Age

Father's Date of Birth

Father's Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Home Phone

Father's Cell Phone

Father's Work Phone

Employed by:

Parents 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.

Client's or Authorized Person's Signature

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.