Treatment Plan Acknowledgment Form

Treatment Plan Acknowledgment Form
Client Name *
Date of Birth

Month Day Year
Date
Therapist
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By signing below, I attest that I have particpated in the treatment plan development and/or review process with the therapist at Aspire Wellness Center for the client named above (myself or child/individual in my care).

I acknowledge and accept the plan for treatment.

I acknowledge review and receipt of client rights and responsibilities, grievance procedure, and procedure for discharge.
Signature of Client/Parent or Guardian

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Printed name of Authorized Signer

First Name Last Name
Date

Month Day Year
Date
Relationship to signer
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