Form A SoleCustodySansLegalDocs DE FACTO

      FORM A

 

 

 CONSENT FORM FOR CROSSROADS TREATMENT SERVICES

DE FACTO SOLE CUSTODY WITHOUT LEGAL DOCUMENTS

 

PARENT/GUARDIAN CONSENT 

 

 I, the undersigned                                                   ____________, declare that I have de facto sole custody of

(Parent/guardian name

 

                                                       ___________________________, 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 de facto sole custody 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 de facto sole custody                                    Date

 

 

 

 

 

 

 

 

 

Child & Family Clinic Hours

BY APPOINTMENT ONLY.

Let us know if you would prefer an in-person,  phone, or virtual session when booking your appointment.

WEDNESDAY 9am – noon  and

THURSDAY  Noon-8pm 

 

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