Treatment Plan ReviewPlease enable JavaScript in your browser to complete this form. Signature: Parent Status: Date:Individual's Name:FirstMiddleLastConsent Status:Individual is of legal age of consent.Individual is under the care of a custodial parent or legal guardian. (please list name and relationship below)Custodial Parent or Legal Guardian Name:FirstLastRelationship to the Individual:Consenting Signature:Note: Custodial Parent or Legal Guardian signature is required if the Individual is under 18 years of age.Consent:I acknowledge receipt and participation in identifying the treatment goals and objectives prepared for me (or the individual under my care). I have reviewed and agreed to the treatment goals discussed. I will provide feedback and review progress towards this treatment goals on an ongoing basis with the therapist/counselor.Signature Status:I AFFIRM that I am an individual of legal age consent.AFFIRM that I am the legal representative of the individual.Consenting Signature: * Clear Signature Date Signed:Submit
