Treatment Plan Acknowledgement Form

Name

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Outpatient Mental Health Clinic (OMHC) & Psychiatric Rehabilitation Program (PRP)

(Adults and Minors | CARF / COMAR / Medicaid Aligned)

CLIENT INFORMATION

Client Name:

Date of Birth:

MRN / Client ID:

Program(s) Receiving Services (check all that apply):

Outpatient Mental Health Clinic (OMHC)

Psychiatric Rehabilitation Program (PRP)

Client Status:

Adult (18 years or older)

Minor (under 18 years of age)

ACKNOWLEDGEMENT OF TREATMENT / REHABILITATION PLAN

I acknowledge that my Individualized Treatment Plan (ITP) and/or Individual Rehabilitation Plan (IRP) was developed with my participation (and with parent/legal guardian participation when applicable), in accordance with applicable COMAR regulations, CARF standards, and Medicaid documentation requirements.

I confirm and acknowledge that:

• The plan is person-centered and individualized, based on assessment, diagnosis, identified needs, strengths, preferences, and goals.
• The goals, objectives, services, interventions, and supports have been explained in a manner that is understood.
• The services identified are medically necessary and address mental health, functional, and/or rehabilitation needs.
• The client and/or guardian had the opportunity to ask questions and participate in planning
• The plan will be reviewed and updated at required intervals or as needs change.
• The client has the right to participate in treatment decisions and request changes.

By signing below, I acknowledge that I have received, reviewed, and agree to this plan.

CLIENT ACKNOWLEDGEMENT (Required for adults; for minors when appropriate)

Client Name (Printed):

Client Signature:

Date:

PARENT / LEGAL GUARDIAN ACKNOWLEDGEMENT (Required for Minors)

Guardian Name (Printed):

Relationship to Client:

Signature

Date:

STAFF ATTESTATION

I attest that this plan was developed and reviewed in compliance with OMHC and/or PRP COMAR regulations, CARF standards, and Medicaid documentation requirements.

Staff Name (Printed):

Title / Credentials:

Program:

OMHC

PRP

Staff Signature:

Date:

TELEHEALTH / COMMUNITY-BASED SERVICES ACKNOWLEDGEMENT (If Applicable)

I acknowledge and consent to OMHC and/or PRP services being provided via telehealth and/or community-based settings when clinically appropriate and permitted under COMAR and Medicaid guidelines.

Client / Guardian Signature:

Date:

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