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
