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719-999-8779
Client:
Client
Submitted By:
Submit by
Begin Date:
Date
End Date:
Date
Rights Modification Informed Consent
Description of your proposed Rights Modification
signDescription
The reason for your Rights Modification, based on your assessed needs
signReason
Other ways you have been supported that have not worked on their own
signOtherSupports
These are things you can do to have your rights restored, and how your service provider will support you and track how you’re doing
signRestorationPlan
This is how the Rights Modification will affect your daily life, and how your staff will support you to avoid harm and discomfort because of the modification
signDailyImpact
You do not have to consent to this proposed Rights Modification. Here are some other options.
signOtherOptions
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