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Client First Name
*
(Needed for file sorting)
First Four Letters of Client Last Name
*
(Needed for File Sorting)
Clinician Name
*
Clinician Email Address
*
Ask you clinician for their email address and enter it in this box
Treatment Plan Development
Client and Clinician must fill out together
Client Name
*
First Name
Last Name
Email
*
example@example.com
Date Completed:
*
/
Month
/
Day
Year
Date
I/We (client/guardian) have actively participated in the development of this service plan and understand the treatment goals and objectives listed. I/We have the following response:
*
I/We (agree/disagree) with this service plan
*
Agree
Disagree
Client (14 or older) Signature
If client is unable to sign state reason and NA in client signature above
Date
*
/
Month
/
Day
Year
Date
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
Relationship to client
CLICK ON NEXT and then SUBMIT
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Witness Signature
Date
-
Month
-
Day
Year
Date
*Responsible MHP
Degree/License
Responsible MHP Signature
Date
/
Month
/
Day
Year
Date
Individual Psychotherapy
Enter frequency (per month)
Responsible MHP and credentials for Ind Psychotherapy
Responsible MHP for Ind Psychotherapy Signature
Date
-
Month
-
Day
Year
Date
Family Psychotherapy
Enter frequency (per month)
Responsible MHP and credentials for Fam Psychotherapy
Responsible MHP for Fam Psychotherapy Signature
Date
-
Month
-
Day
Year
Date
Group Psychotherapy
Enter frequency (per month)
Responsible MHP and credentials for Group Psychotherapy
Responsible MHP for Group Psychotherapy Signature
Date
-
Month
-
Day
Year
Date
P/S Rehab Individual
Enter frequency (per month)
Responsible MHP and credentials for P/S Rehab Ind
Responsible MHP for P/S Rehab Ind Signature
Date
-
Month
-
Day
Year
Date
P/S Rehab Group
Enter frequency (per month)
Responsible MHP and credentials for P/S Rehab Group
Responsible MHP for P/S Rehab Group Signature
Date
-
Month
-
Day
Year
Date
Case Management
Enter frequency (per month)
Responsible MHP and credentials for CM
Responsible MHP for CM Signature
Date
-
Month
-
Day
Year
Date
Psychological Testing
Enter frequency (per month)
Responsible MHP and credentials for Psych Testing
Responsible MHP for Psych Testing Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: