Behavioral Health Consent to Treatment
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who do you see for counseling services?
By my signature below, I acknowledge that I have actively participated in the development of the care plan on this date and agree with the treatment recommendations and expectations of treatment.
I agree
I do not agree
Signature
Continue
Continue
Should be Empty: