FORM A
CONSENT FORM FOR CROSSROADS TREATMENT SERVICES
SOLE CUSTODY (DECISION MAKING) WITHOUT LEGAL DOCUMENTS
PARENT/GUARDIAN CONSENT
I, the undersigned ____________, declare that I have sole
(Parent/guardian name)
decision making of
___________________________, and accept that they
(child’s name and date of birth)
participate in treatment services at Crossroads Children’s Mental Health Centre. I declare that I have sole custody (decision making) of my child; however, I declare that I do not have any legal documents to attest this custody.
I have been advised that I have the right to withdraw my consent at any time.
_____________________________________ ___________________________________
Parent/guardian’s signature – whoever has sole custody Date
