Service Plan Signature Page

Service Plan Signature Page
Today's Date

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Date
Client Name*

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Client DOB*

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Client ID
CLIENT'S ACKNOWLEDGEMENT

I HELPED DEVELOP THIS PLAN AND/OR REVIEWED WITH MY CARE COORDINATOR, AND APPROVE OF ITS CONTENTS. I HAVE BEEN OFFERED A COPY OF MY SERVICE PLAN.

27/65 ADDENDUM:

I have been offered the opportunity to participate in the development of my Service Plan and I have been offered a copy of the plan. Staff advised me that I can contact the Client Advocate at 719-423-1381 if I have complaints or concerns about my care.
By signing your name electronically on this document, you are agreeing that the signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.*

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