Form D SharedCustodySansLegalDocsEXEMPTIONS

      FORM D

 

 CONSENT FORM FOR CROSSROADS TREATMENT SERVICES

SHARED CUSTODY (DECISION MAKING) WITHOUT LEGAL DOCUMENTS/

EXEMPTION SITUATIONS

 

PARENT/GUARDIAN’S CONSENT 

 

I, the undersigned                                                   ____________, declare that I have shared

(Parent/guardian’s name)

Custody (decision making) of

 

                                                       ___________________________, and accept that they

(child’s name and date of birth)

 

receive treatment services at Crossroads Children’s Mental Health Centre. Our present family situation prevents me from informing the other parent about this process due to:

 

□ intimate partner violence

□ living in a shelter

□ no contact order □ legal document attached

□ out of the country and unable to contact

□ not able to obtain the other parent’s coordinates

□ other parent/guardian in prison

□ other exemption situation______________________________________________________.

 

 

I have been advised that I have the right to withdraw my consent at any time.  If any of the above conditions ever change, I will advise Crossroads Children’s Mental Health Centre.     Another form will then be given to me to complete.

 

_____________________________________________             ___________________________________

Parent/guardian’s signature – with shared 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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