Acknowledgment of Receipt of Information (SUD)

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
- HIV / AIDS Information
- Tuberculosis Information
- Opioid Information
- Testing Centers
Client Information
Legal Name *

First Name Last Name
Preferred Name

First Name Last Name
Date of Birth *

Month Day Year
Please indicate your relationship *

Self Parent Legal Guardian Conservator Health Care Agent / Health Care Power of Attorney
Parent Name *

First Name Last Name
Name of Legal Guardian *

First Name Last Name
Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name
My signature indicates that I am legally authorized to sign on behalf of the client.
Signature *

Clear
Date *

Month Day Year
Should be Empty: