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
