Level of Care Change & Step-down Acknowledgment


Level of Care & Step-down Acknowledgement

Use this form to document your acknowledgement of changes in your level of care, intensity and housing credit reduction.

"*" indicates required fields

Hidden
MM slash DD slash YYYY

Client Information

Client Name*




Programming Change



MM slash DD slash YYYY


Current Status

Current Program
Current Schedule Type
Current Intensity
Enter NA if not applicable


New Status

New Program
New Schedule Type
New Intensity
Enter NA if not applicable




Level of Care Acknowledgement

Change in Level of Care and Housing Credit Agreement*
Please review and acknowledge your agreement with the following process and terms.

By signing this form, you are acknowledging a change in your level of care, program intensity, and/or housing credit. These changes are indicated above and take effect on the indicated date.

By signing this form you’re attesting that you understand all of the information contained in this memo.