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BH Acknowledgment of Treatment Goals and Service Planning

 
I acknowledge that I have participated in the development of a service plan dated
  for myself (or my minor child):
 
 
I have reviewed with my care manager my diagnosis and progress which indicates my agreement with the course of treatment dictated by my service plan. I have been offered a copy of my service plan.
Client/Guardian Name:

Date of Birth:

 Provider Name:
 
Client/Guardian Signature                                                        
                                                                 

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