Mental Health ITP Signature Page - Client Self-Service

Use this form to acknowledge participation in the development of your service plan.
Once you complete this form, you’ll be taken to a new page to sign it.

Use this form to document your consent for the individual service plan.

Today's Date*
MM slash DD slash YYYY
Are you the client or the parent/guardian?*
- Client
- Parent/Guardian
Client Name:*
First Last
Client's Date of Birth*
Name of Person Signing this Form*
This may be the client, or the parent/guardian.
First Last
Email of Person Signing Form:*
This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email.
MNCP Therapist's Name (if known)
Phone
This field is for validation purposes and should be left unchanged.