FORM B
CONSENT TO CROSSROADS TREATMENT SERVICES
SHARED CUSTODY (DECISION MAKING)
PARENT/GUARDIAN’S CONSENT
I, the undersigned ____________, declare that I have legal
(parent or guardian)
shared custody (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 commit to informing the other parent of any clinical interventions and to sending them Form C in order to have them complete it and return it to Crossroads Children’s Mental Health Centre.
I have been advised that I have the right to withdraw my consent at any time.
_____________________________________________ ___________________________________
(Parent/Guardian’s signature) Date
