Treatment Plan Extension Consent and Agreement

Treatment Plan Extension Consent and Agreement

Telehealth Services
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Guardian Name

First NameLast Name
I/We hereby consent to receive Telehealth services and have completed the Informed Consent for Telehealth Services.
Initials*
I/We participated in the development of the Transition/Aftercare Plan and agree to the information listed.
Initials*
I/We participated actively participated in the development of the service plan and understand the treatment goals and objectives listed, and provided a statement in regards to both.
Initials*
Client Signature (14 or older)*
Date*

MonthDayYear
Date
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty: