Client's Name * First Name Last Name Client's Birthdate * MM DD YYYY My signature below acknowledges that the Treatment Plan of the above listed client has been reviewed with the client (age appropriately) and me. Please email a copy of this document to me at the email listed below. Lack of an email in the below box indicates that I already have a copy or do not wish to have a copy of this document. Email * Signature * Printed Name of Signature Above * Thank you! Treatment Plan Acknowledgment
