IM+CANS Signature Page

IM+CANS Signature Page
Client Name:

First NameLast Name
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 mental health assessment and treatment planning process and have received a copy of the completed IM+CANS. I acknowledge that I have reviewed the IM+CANS 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 outlined in the treatment plan and consent to the services as described.
Client Signature:*
Today's Date:*

MonthDayYear
Date
Parent/Guardian Signature:
Today's Date:

MonthDayYear
Date
Should be Empty: