Catalpa Health Mental Health Treatment Plan Approval Form

Complete and electronically sign this document when instructed to by your provider.

Contact Phone Number:*
In the event that there is an error with the form submission, we will need to contact you directly. Please provide the best phone number to reach you if follow up is needed.
Catalpa Health Mental Health Treatment Plan Approval Form
First Name of Client*
Last Name of Client*
Client Date of Birth*
Acknowledgement*
I have had an opportunity to participate in planning of my child’s treatment plan and to be informed of the services involved in that plan. In addition, I have had an opportunity to modify the plan, schedule, frequency, and nature of the services recommended. At any time I would like to review and modify this plan I have an opportunity to do so by contacting my child’s provider.
Name of Parent/Legal Guardian*
First Last
Signature of Parent/Legal Guardian
Signature of Parent/Legal Guardian*
Date of Signature*
Date of Signature
MM slash DD slash YYYY
Signature of Client (if age 14 or older)
Signature of Client (if age 14 or older)
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