Treatment Plan Acknowledgement eSignature


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: Treatment Plan Acknowledgement eSignature
lock iconUnique Document ID: 811f10e605b5d06e9895c5c488bfcd2eb56b69b1
Timestamp Audit
November 26, 2019 8:50 am CSTTreatment Plan Acknowledgement eSignature Uploaded by Justin Scharr - justinscharr@mncarepartner.com IP 174.53.135.153
November 26, 2019 9:13 am CSTRoots 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 CSTRoots 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 CSTRoots 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 CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153