Services Requested
Frequency
(per visit, per request, daily, weekly, etc.)
Documentation & Information:
I acknowledge that the information and documentation as noted above, has been discussed with me and I will be provided with a copy.
Client Consent:
I consent to have the Non-Medical Home Services as requested and recorded in this Service Plan. I understand that my service requests/needs will be reviewed by the Supervisor at least every_______ months, or as required, and that the service(s) may be changed according to my needs, wants or wishes.
