Alpha & Omega Therapy and Doula Services Inc. Client Mental Health Signature Page
Phone: 918-812-5315
Client name
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I/We (Client/Guardian) have actively participated in the development of this treatment plan and understand the treatment goals and objectives listed. I/We have the following response:
I/We with this services plan.
Agree
Disagree
Client Signature 14 years or older
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to client
If client can not sign the document, please choose reason:
Client is underage
Client is disabled and can not write his/her name
Other reason, client can not sign his/her name
Submit
Submit
Should be Empty: