Custody Consent Form
Name of Child
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Parents
Name of Father
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Mother
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Same address as above
Yes
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Status of Parents
Married
Living Together (not married)
Separated
Divorced
Other
Custody Arrangement
Joint Custody
Sole Custody
No Custody Arrangement
Guardianship
Other
I hereby authorize the Clinic to conduct an assessment and/or treatment to our child, {nameOf}.
Signature
Clear
Name
First Name
Last Name
Submit
Should be Empty: