• Acknowledgment of Receipt of Information

  • My signature below indicates that I have received the following written information from Northwestern Mental Health Center, Inc. and that the documents have been discussed with me by staff.

    • Program Abuse Prevention Plan
    • STD Information
    • Hepatitis Information
      • Hepatitis A
      • Hepatitis B
      • Hepatitis C
    • HIV / AIDS Information
    • Tuberculosis Information
    • Opioid Information
    • Testing Centers
  • Client Information

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  • My signature indicates that I am legally authorized to sign on behalf of the client.

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  • Should be Empty: