In consideration of my participation in the OTIK HEALTH CARE SERVICES, LLC

1. Allow OTIK HEALTH CARE SERVICES, LLC to complete an assessment regarding my
services (If Applicable).

2. Have written records maintained of my participation while receiving services from
OTIK HEALTH CARE SERVICES, LLC.

3. Have records of my participation used for purposes of developing an individualized plan.

4. The participation of consultant’s, under the supervision of the OTIK HEALTH CARE
SERVICES, LLC Program Manager in various training aspects of the program, including
evaluations, team and quarterly review meetings, record keeping, admissions, discharges,
and quality assurance of program services.