Roots Treatment Plan Acknowledgement - Staff Requested


Treatment Plan Participation Acknowledgement

Client Name: 
Date of Birth:
Primary Counselor:


By signing this form, I acknowledge that I have participated in the development and revision of my individualized treatment plan and agree with the contents of the plan.

I also acknowledge that any items marked “Must be reached to have services terminated” must be completed before I am able to complete the primary phase of the treatment program with a “successful completion” designation.

Leave this empty:

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Signature Certificate
Document name: Roots Treatment Plan Acknowledgement - Staff Requested
lock iconUnique Document ID: 2b918ff273379e76996750759839ac51c41040d8
Timestamp Audit
July 20, 2020 2:32 pm CSTRoots Treatment Plan Acknowledgement - Staff Requested Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.190.44
July 20, 2020 3:26 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
July 20, 2020 3:27 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
July 21, 2020 1:51 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153