Treatment/FBA Plan Signature Page

Treatment/FBA Plan Signature Page
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Client Email:*
example@example.com
Clinician Name:*

First NameLast Name
Clinician's Email (format is first initial last name@bluekitewellness.com for example John Doe would be jdoe@bluekitewellness.com):*
example@example.com
I confirm that I have participated in the development of the treatment plan or Functional Behavioral Assessment plan and have received a copy. I acknowledge that I have reviewed the plan in full and that its contents have been explained to me in a language I understand. I understand the risks and benefits of the services described in the plan and I consent to the services outlined.
Parent/Legal GuardianYouth (Only if 18 or older)
Signature:*
Today's Date:*

MonthDayYear
Date
Should be Empty: