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Ausblick Therapie GmbH
Parent Caregiver Acknowledgement
Child’s name
First
Last
Guardian's name
First
Last
Is parent/caregiver involved in treatment plan goals?
Yes
No
If No, please indicate why not:
I am familiar with the treatment objective and goals developed for my child and fully cognizant of the care being provided to my child.
Signature of Guardian
Date of signature
MM slash DD slash YYYY