Adult Day Care Assessment/Service Plan/ Plan of Care



Adult Day Care Assessment/Service Plan/Plan of Care

[pic]

Signature Record

|Initials |Print Name |Signature |Title |Date |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Note: An individual’s signature indicates their personal participation in the assessment process and approval of the plan.

THE DEPARTMENT OF HEALTH AND MENTAL HYGIENE HAS NOT CREATED AN ELECTRONIC SIGNATURE POLICY. THIS PAGE MUST BE PRINTED AND SIGNED BY EACH INDIVIDUAL WHO PARTICIPATED IN THE PROCESS.

Rev: February 2012

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download