Treatment Plan Consent (All Programs)

Treatment Plan Consent
Client Information
Legal Name *

First Name Last Name
Preferred Name

First Name Last Name
Northwestern Mental Health Center Provider Name *

First Name Last Name
Service ID *
Please indicate your relationship to the client *

Self Parent Legal Guardian Conservator Health Care Agent / Health Care Power of Attorney
Parent Name *

First Name Last Name
Legal Guardian Name *

First Name Last Name
Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name
I acknowledge that this treatment plan document has been reviewed with me regarding the indicated client, and I as the legal representative, approve the treatment plan as written.
I acknowledge that this treatment plan document has been reviewed with me and I approve the treatment plan as written.
My signature indicates that I am legally authorized to sign on behalf of the client.
My signature indicates that I am legally authorized to sign.
Authorized Signature *

Clear
Date *

Month Day Year
Should be Empty: