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Treatment Plan Acknowledgement eSignature

Treatment Plan Participation Acknowledgement

Client Name: [esigwpform formid="4367" field_id="1" display="value" ] 
Date of Birth: [esigwpform formid="4367" field_id="2" display="value" ] 
Primary Counselor: [esigwpform formid="4367" field_id="3" display="value" ]

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.

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November 26, 2019 8:50 am CDT

Treatment Plan Acknowledgement eSignature Uploaded by Justin Scharr - justinscharr@mncarepartner.com IP 174.53.135.153

November 26, 2019 9:13 am CDT

Roots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 66.41.158.64

May 27, 2020 9:19 am CDT

Roots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153

July 20, 2020 3:26 pm CDT

Roots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153

July 21, 2020 1:54 pm CDT

Roots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153