Treatment Plan Agreement Treatment Plan Agreement Client Name* First Last Birth Date* MM slash DD slash YYYY Medicaid or Insurance #* Treatment Plan Agreement I agree with the treatment plan and acknowledge that I had an opportunity to participate in the development of the plan. I have also been made aware of the client’s right to freedom of choice among sub-providers authorized to provide each service on the treatment plan. The client may request a change in providers and an update to the treatment plan at anytime. Team members agree to keep confidential all information shared about the client Have you read the above explanation of practices?* Yes Signature*Name of Person Signing* Email Address Date* MM slash DD slash YYYY Unique IDRelationship to the client* Client Parent Legal Guardian Behavioral Health Professional Targeted Case Manager Community Support Associate Other Support Person Behavior Analyst Psychiatrist Other Medical Provider
