FORM C
CONSENT FORM FOR CROSSROADS SINGLE SESSION 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 single session 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
I am aware that if I would like to have a single session appointment, I can do so by booking through counsellingconnect.org or calling Crossroads 613-723-1623 extension 232.
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
