Custody Declaration Form

As Roamers Therapy, our responsibility and goal is the well-being of our clients. In the case of a child as the primary client, it is essential that parents and/or legal guardians are in an agreement as to the decision to treat, the treatment goals, appointment times and the need to maintain client confidentiality. As a result, it is the policy of Roamers Therapy that all minors presented for treatment have the following authorization and consent on file.

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Name of the Minor *

First

Last

Choose *

Both parents/legal guardians are living, have legal custody of the minor child and consent to treatment. Both parents/legal guardians will sign this document.
One parent/legal guardian has legal custody of the minor child and only custodial parent/legal guardian will sign this document.
One parent/legal guardian is absent, missing, or deceased and only one parent/legal guardian will sign this document.

Guardian Name Signature

Both Parent/Legal Guardian Consent

Both legal parents/guardians agree to the treatment and providing of mental health services for their child and will indicate their consent below. If there is no custody agreement in place, the parent signing is indicating that both parents are fully aware of and in and support the mental health treatment that is being provided for the minor named below. If the biological or legally adopted parents are currently separated or going through the divorce process, both parents are still required to sign a Consent for Mental Health Treatment Form before the child can be treated.

Parent/Legal Guardian 1

Parent/Legal Guardian 2

I, hereby authorize, with the total understanding of the above-mentioned terms and conditions, my child to receive mental health treatment at Roamers Therapy LLC and assume all financial responsibility for their treatment.

I affirm that I have the authority to make health care decisions for my child and am aware that all custodial parents and legal guardians must give consent before treatment begins.

I understand and agree that any breach of these agreements may result in the termination of any, and all, of my child’s relationship with Roamers Therapy or any of its providers,affiliates, and/or staff members. I have been given the opportunity to ask any questions I may have had and am voluntarily signing this agreement.

I affirm that I have the authority to make health care decisions for my child and am aware that all custodial parents and legal guardians must give consent before treatment begins.

Parent/Legal Guardian 1 Name *

Parent/Legal Guardian 2 Name *

Parent/Legal Guardian 1 Signature *

Clear Signature

Parent/Legal Guardian 2 Signature *

Clear Signature

Date *

Legal Parent/Custodial Legal Guardian Consent

There is an official certified divorce decree or a legal custody order that indicates that only one parent is legally permitted to determine and decide on mental health treatment of the child without the consent of other parent (In this case, please provide us with a certified copy of this legal document in its entirety).

I affirm that I have the authority to make health care decisions for my child and am aware that all custodial parents and legal guardians must give consent before treatment begins.

Legal Parent/Custodial Legal Guardian Name *

Legal Parent/Custodial Legal Guardian Signature *

Clear Signature

Date *

Custody Documents *

Click or drag files to this area to upload. You can upload up to 5 files.

Please provide legal documentation confirming your status as the custodial legal guardian or parent, such as a court order, custody agreement, or birth certificate.

Sole Parent/Legal Guardian Consent

The parent/legal guardian presenting child for treatment has no access to other parent due to the following reasons (death, incarceration, missing, has left and made no contact, etc.) and therefore will acknowledge that they are the sole primary caretaker of the child for mental health treatment and will bare all responsibility for such consent.

I affirm that I have the authority to make health care decisions for my child and am aware that all custodial parents and legal guardians must give consent before treatment begins. I stipulate that a good faith effort was made to obtain the consent of the other parent, but this parent is either completely uninvolved in the child’s life, the parent was not reachable/did not respond to efforts to reach him/her, and/or is not capable of informed consent.

I understand that given circumstances in which the other parent is not reachable, completely uninvolved in the child’s life (no contact at all with the child for at least several years), or incapable of informed consent), Roamers Therapy will provide treatment for my child without the consent of the child’s other parent. However, I agree that if the child’s parent should become available or involved in the child’s life that this parent’s consent will be required for treatment and that I will adhere to the policies regarding the Parent Authorization, Agreement, and Consent for Treatment of Child.

I hereby swear and affirm under any applicable perjury laws that there is no legal divorce decree, custody order, or separation agreement that restricts or limits me from making any or all decisions in regard to my child’s mental health treatment. I further acknowledge that Roamers Therapy, LLC has asked and attempted to collect any and all such documents from me.

I further acknowledge and agree that it is ultimately my responsibility to make sure that I am following all legal conditions set forth by my divorce decree, separation agreements, etc. and acknowledge that Roamers Therapy LLC is only requesting any and all related documents for the benefit of my child and therefore release any liability to Roamers Therapy, LLC, any of its providers, office staff, and/or affiliates resulting from a dispute to this authorization.

I understand and agree that any breach of these agreements may result in the termination of any and all of my child’s relationships with Raomers Therapy or any of its providers, affiliates, and/or staff members. I have been given the opportunity to ask any questions I may have had and am voluntarily signing this agreement.

Sole Parent/Legal Guardian Name *

Sole Parent/Legal Guardian Signature *

Clear Signature

Date *

Custody Documents *

Click or drag files to this area to upload. You can upload up to 5 files.

Please provide legal documentation confirming your status as the custodial legal guardian or parent, such as a court order, custody agreement, or birth certificate.