CLIENT CHOICE FORM

DOB: MID#

By placing my name above, I understand that NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER is a voluntary program and that my participation in the program is by:

I understand that there are a number of providers qualified to provide the same services offered by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER and these providers are ready to provide behavioral health services to me.

After being offered the above choices I have selected NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER to provide this service.

No one has exerted pressure on me to select NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER and I am confident that this provider is best suited to meet my behavioral health needs.

I understand that if I find that NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER does not meet my needs, I may select another provider to replace NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER at any time.

Signature of Client/Guardian:

Printed Name of Client/Guardian: Date:

Signature Name of Witness (Intake Therapist):

Printed Name of Witness:

The Witness is responsible to assure that the authorizing party signing has full knowledge of what s/he is signing and is able to grant consent.