Treatment Plan Review Date MM slash DD slash YYYY Individual Receiving ServicesIndividual's Name First Middle Initial Last Suffix Consent 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 GuardianCustodial Parent or Legal Guardian Name First Last Suffix Relationship to the Individual Consenting SignatureNote: 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.SignatureSignature Status I AFFIRM that I am an individual of legal age consent. I AFFIRM that I am the legal representative of the individual. Signature Date MM slash DD slash YYYY Δ
