Adult Freedom of Choice Form

Client Name:
Insurance ID#:
DOB:
Freedom of Choice Form
Individual/guardian shall choose a provider for each service identified on your treatment/care plan. Document providers/agency chosen to the right of each service.

I understand that the choice of providers is my responsibility and right as the parent/guardian. I further understand that I have the right to contact the providers prior to selection so that I may determine the best provider for my child. I also understand that I may at any time choose another provider for this service by notifying my current provider.

The individual/guardian shall initial each service to be provided.
Individual Therapy
Signature

Clear
Collateral Therapy
Signature

Clear
Family Therapy
Signature

Clear
Group Therapy
Signature

Clear
Case Management
Signature

Clear
Other
Signature

Clear
I have reviewed the list of provider(s) in my area and chosen the providers identified above.
Signature

Clear
Date:

MonthDayYear
Date
PPC Representative:
Should be Empty: