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.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Mental Health ITP Signature Page - Staff Requested
Agree & Sign