Attestation Form

Patient Attestation Form/Participation in the Development of the Plan of Care

verify that I have participated in the development of the plan of care with my service provider, and that the plan of care is based upon my unique need and circumstances, as reported. I understand that an interdisciplinary team approach will be utilized for the achievement of this plan of care when warranted. 

In signing this attestation I declare that my views and choices have been considered in the plan of care development.

For children: As Parent/Guardian of the child specified above, I give permission for collateral services on behalf of child.

Date of initial plan of care:   


Name of Patient (or Parent/Guardian):  January 22, 2019

Witness/KCC Staff Member:  January 22, 2019


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Kentucky Counseling Center
Signature Certificate
Document name: Attestation Form
Unique Document ID: 2940a83a587c46efa879b0b342d98695f9c76bd6
Timestamp Audit
October 14, 2018 8:50 pm ESTAttestation Form Uploaded by Matt Grammer - IP