Telehealth Treatment Plan Participation Form
1900 Brice Rd. Reynoldsburg, OH 43068 P: (614) 239-9965 F: (614) 239-9971
Client Name
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First Name
Last Name
Client DOB:
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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.
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My therapist at WCAP Counseling reviewed and discussed my Individualized Treatment Plan (ITP) with me
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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.
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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.
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Date signed:
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Client Signature
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