Telehealth Treatment Plan Participation Form
1900 Brice Rd. Reynoldsburg, OH 43068 P: (614) 239-9965 F: (614) 239-9971
Client Name
*
First Name
Last Name
Client DOB:
*
-
Month
-
Day
Year
Date
I acknowledge with my initials and signature below, the following:
I understand that due to the COVID-19 public health emergency, Telehealth services are being offered to me by WCAP Counseling which include a remote treatment planning process.
*
My therapist at WCAP Counseling reviewed and discussed my Individualized Treatment Plan (ITP) with me
*
I acknowledge that I was an active participant in the review of my treatment plan and agree to the goals and objectives that were shared with me by my therapist.
*
I understand that if I would like to view my treatment plan in more detail I can login to my client portal at www.wcapcounseling.org.
*
Date signed:
-
Month
-
Day
Year
Date
Client Signature
Submit
Should be Empty: