Mental Health ITP Signature Page - Staff Requested


393 Dunlap St N, Ste 300
Saint Paul, MN 55104

 

Mental Health ITP Services Plan Acknowledgement

 

Client Name:      
Client Date of Birth:    

Person Signing this Form is the:  

Name of Person Signing this Form:     

Name of staff member requesting signature:

 

My signature on this document indicates participation and agreement on the development of the service plan for the services I have consented to receive. This may include an individualized treatment plan, crisis plan, or any other service plan designed to outline the goals, methods, objectives or therapeutic interventions to be used during the service process. Client or guardian signature also indicates that the client/guardian has access to a copy of the client rights and responsibilities as well as a copy of the associated service plan upon request.

 

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Signature Certificate
Document name: Mental Health ITP Signature Page - Staff Requested
lock iconUnique Document ID: 70725e41f254bdf4c1370beb337d478e73c68a49
Timestamp Audit
September 10, 2020 12:26 pm CSTMental Health ITP Signature Page - Staff Requested Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 174.53.135.153
September 10, 2020 12:27 pm CSTMNCP Intake - intake@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
September 10, 2020 12:34 pm CST Document owner rootsforms@mncarepartner.com has handed over this document to referrals@mncarepartner.com 2020-09-10 12:34:13 - 174.53.135.153
September 10, 2020 12:34 pm CSTMNCP Intake - intake@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153