Agreement to Participate in Positive Behavior Support Plan

AGREEMENT TO PARTICIPATE IN POSITIVE BEHAVIOR SUPPORT PLAN
The intended outcome and nature of, and the procedures involved in, participating in the proposed treatment or activity have been explained to me in a manner that / understand. / understand the benefits and the risks, including side effects of the proposed treatment or activity, as well as the risks of not proceeding.

understand that / am free to withdraw consent at any time without the threat of punishment. This consent expires after one year.
I,name* understand that the attached is a voluntary plan for my personal growth and well being. I agree to participate and follow the plan as explained to me by name* .
Individual's Signature*

Clear
Date*

MonthDayYear
Date
Procedure used to obtain consent:
Signature of Person Obtaining Consent*

Clear
Date*

MonthDayYear
Date
Legal Guardian's Signature*

Clear
Date*

MonthDayYear
Date

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AGREEMENT TO PARTICIPATE IN POSITIVE BEHAVIOR SUPPORT PLAN