LES TX Treatment Plan Acknowledgement

LES TX Treatment Plan Acknowledgement

Please review the acknowledgment, confirm your understanding, and sign below.
Name

First NameLast Name
I acknowledge that my current plan has been reviewed with me by my provider. The goals, objectives, and services included in my treatment plan have been explained in a way I understand, and I have had the opportunity to ask questions.By signing this form,

I confirm that I:

(1) Have reviewed and discussed my treatment plan with my provider.

(2) Understand the services, goals, and objectives outlined in my plan.

(3) Agree that this treatment plan reflects my needs and preferences.This acknowledgment is being signed to meet compliance requirements. It serves as a duplicate signature for legal purposes only. Signing this form does not create or authorize any additional services outside of the scope of my existing treatment plan.
Acknowledgment of treatment plan review and understanding
Acknowledgment that treatment plan reflects needs and preferences
Signature Date

MonthDayYear
Date
Signature
Should be Empty: