Mutual Responsibility Contract Acknowledgement

Mutual Responsibility Contract Acknowledgement

Use this form to document your acknowledgement of a mutual responsibility contract, items required for completion, and your involvement in the treatment planning process.

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Client Information

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Mutual Responsibility Contract Acknowledgement

Treatment Planning Process Explanation and Agreement*
Please review and acknowledge your agreement with the following process and terms.

By signing this form you are acknowledging the following:
• You have participated actively in the development of your mutual responsibility contract.
• You are aware of and in agreement with the dates and expectations of your mutual responsibility contract.
• You understand the goals on the contract that must be met for successful completion.
• You understand the criteria that must be met for successful completion.
• You are aware of and in agreement with any changes that have been made to the contract, including any description of risk, problem or progress.

By signing this form you’re attesting that you understand all of the information contained in this memo.