Treatment Plan Signature Page

Treatment Plan Signature Page
What is the name of your provider?
Effective Date of Treatment Plan
Client Name

First NameLast Name
By signing below, I acknowledge that I/we have participated in the development process of this treatment plan. I/we understand that changes can be made to this treatment plan at any time and when clinically indicated.
Client Signature/Legally Responsible Party/Guardian

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Email
example@example.com
Signature Date
Email
example@example.com
Should be Empty: