MH Intake ITP Signature Page - Client Self-Service


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

 

Mental Health Services Plan (ITP) Acknowledgement

 

Client Name:    
Client Date of Birth:    

Person Signing this Form is the:     

Name of Person Signing this Form:    

 

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: MH Intake ITP Signature Page - Client Self-Service
lock iconUnique Document ID: cb900b1b398f022a8146fd7c9e54a63ef2fda130
Timestamp Audit
August 6, 2020 10:41 am CSTMH Intake ITP Signature Page - Client Self-Service Uploaded by MInnesota CarePartner - referrals@mncarepartner.com IP 174.53.135.153
August 6, 2020 10:48 am CSTClient Info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:48 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:55 am CSTClient Info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:55 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:13 am CSTClient Info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:13 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:23 am CST Document owner rootsforms@mncarepartner.com has handed over this document to referrals@mncarepartner.com 2020-08-06 11:23:40 - 174.53.135.153
August 6, 2020 11:23 am CSTClient Info - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:23 am CSTClient Referrals - referrals@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:42 am CSTClient Info - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:42 am CSTClient Referrals - referrals@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153