Form C SharedCustodyWITHLegalDocsTREATMENT

      FORM C

 

CONSENT FORM FOR CROSSROADS TREATMENT SERVICES

SHARED CUSTODY (DECISION MAKING)

 

OTHER PARENT/GUARDIAN’S CONSENT 

 

 

I, the undersigned                                                   ____________, declare that I have legal

(parent/guardian name)

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 have been advised that I have the right to withdraw my consent at any time.

 

 

_____________________________________________                                                             ___________________________________

Parent/guardian’s signature – with shared custody                                             Date

 

Please indicate how you would like to be involved in treatment services, if at all:

 

□ I will not participate in treatment

□ I would like a copy of the treatment plan

□ I would like to be involved in the treatment process*

 

*If you indicated that you would like to be involved in the treatment process, a member of the Crossroads team will reach out to you when your child is admitted into services.

 

If you would like more information about this form, please call 613-723-1623 or email info@crossroadschildren.ca

 

For more information about Crossroads Children’s Mental Health Centre, please visit our website at https://www.crossroadschildren.ca

 

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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