Child Freedom of Choice

Client Name:
Medicaid/Insurance ID#:
DOB:
Freedom of Choice Form
Parents/Guardians shall choose a provider for each service identified on your child’s treatment/care plan. Document providers/agency chosen to the right of each service.
As the parent/guardian of
, I understand that the choice of

providers is my responsibility and right as the parent/guardian. I further understand that I have the right to contact the providers prior to selection so that I may determine the best provider for my child. I also understand that I may at any time choose another provider for this service by notifying my current provider.

The parent/caregiver shall initial each service to be provided.
Individual Therapy:
Signature

Clear
Collateral Therapy:
Signature

Clear
Family Therapy:
Signature

Clear
Group Therapy:
Signature

Clear
Case Management:
Signature

Clear
Other (list):
Signature

Clear
I have reviewed the list of provider(s) in my area and chosen the providers identified above.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
PPC Representative:
Should be Empty:

Freedom of Choice Form