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Adult Information Form

Michael J. Brown, MSC, LMFT

Happy Couples Healthy Communities

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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.