LetterofConsentForYourChildtoReceiveServices: ForSeparatedParentsorGuardians

NameofChild(ren):

1

Introduct ion: Our Goal for Service at ROCK

ReachOutCentreforKids(ROCK)isamulti-serviceorganizationprovidingchildandfamilytreatmentservicesthatworkswithfamiliestoimprovethelivesandrelationshipsofchildrenwiththeirparents.Wecanworkwithfamiliesthataregoingthroughaseparationordivorce.Thechildrenweworkwithusuallylivewithparent(s)orguardian(s)[Hereafterreferredtoasthe“parent(s)”].ROCKunderstandsthatthereisawiderangeofdecision-makingarrangementsforchildrenandwewillrespectthat.Wherethereissharedparentingtimebetweentheparents,ROCKconsidersitimportanttosupporttheparentingrelationshipwiththechildandeachparent.

UnderstandingDecis ion-MakingandConsent for Service

ThisLetterisanimportantstepforROCKtounderstandifoneorbothparentsneedtoprovideconsentforservicesforyourchild.ROCKwillneedtobeclearthatbothparentsareinagreementthattheirchildcanreceiveservicebeforeweproceed.Tobespecific,ROCKneedstounderstandifdecisionmakingforyourchildisthroughashareddecisionmakingprocess(alsocalledcustody)tobothparents,orifdecisionmakingabilityhasbeengiventoasingleparent.Evenwhendecision-makingisgiventoasoleparent,awrittenagreementmaystatethattheotherparentstillneedstobeInvolvedinserviceand/orInformedofthechild’sprogressinservice.Toaidusinbecomingclear,ROCKwillaskiftherehasbeenawrittenagreement.SomeofthefamiliesthatweseeatROCKhavenowrittenagreement,whileothershaveawrittenagreementthathasbeencreatedwithalawyer,amediator,orthroughalegalcourtprocess.Theseagreementsoftenhelpustoanswerthequestionofwhocangiveconsentforyourchildtoreceiveservice.

Consent for Service - Whatthis Meansfor You:

o 1.YoumayhaveNoagreementforthedecisionmakingofyourchild(ren).

Ø Ifso,ROCKwillaskbothparentstosignthisletterbeforeweprovideserviceforyourchild(ren).

o 2.YoumayhaveaSharedDecision-MakingAgreementthroughaJointCustodyAgreement,a

SeparationAgreementorinanInterimagreementfromafamilycourt.

Ø Ifso,ROCKwillaskbothparentstosignthisletterbeforeweprovideserviceforyourchild(ren).

o 3.YoumayhaveSoleDecision-MakingAbilitythroughaCourtOrderoraSeparationAgreement

thatallowsyoualonetoprovideconsentforyourchildtoreceiveservice.

Ø Ifso,ROCKwillaskthatyouconfirmthatyoucanprovideconsentforservicesbysigningthisletterbelow.

LetterofConsentForYourChildtoReceiveServices: ForSeparatedParentsorGuardians

NameofChild(ren):

2

PleaseNote:Evenwhendecision-makingisgiventoasingleparent,thewrittenagreementmaystillstatethattheotherparentneedsto:

i. GivePermission:Theotherparent'spermissionmaystillberequiredspecificallyforyourchildtoreceivementalhealthservices.

ii. BeInvolved:Youragreementmaystillrequire/encouragetheinvolvementoftheotherparentinservicewithyourchild.

iii. BeInformed:Theotherparentmaynotneedtoconsentorbeinvolved,butyoumaystillberequiredtoinformthemoftheoutcomesofservice.

PleaseNote:Thereareparentsthathavethesoleabilitytoprovideconsentforservicewhostillchoosetoinvolvetheotherparent.Wherethereissharedparentingtimewewillinquireaboutpossiblebenefitsofincludingtheotherparentorguardian.

Signatureof Understanding

Ifyoubelievethatyouhavethepermissiontoconsenttoyourchild'sservicepleaseindicatewhichoptionaboveappliestoyouandsignyournamebelow.

Iftheconsentoftheotherparentisrequired,pleasehavethemindicatetheirconsentforustoprovideservicebysigningbelow,orbyreturningacopyofthisletter.

ArethereSafetyConcerns?

Ifyoufeelthatyouoryourchildareatriskofphysicalharmbytheotherparent,wewillnotaskfortheirconsentfortreatment.Bysigningbelow,youarelettingusknowthatyoufeelunsafe,andthatROCKshouldnotcontacttheotherparent.

LimitsofConfidentiality:

Pleasebeawarethattheinformationthatyoushareinyoursession(s)arekeptinyourchild'sfile(alsocalledaHealthInformationRecord).ROCKworkshardtokeeptheinformationinyourchild'sfileconfidential.However,therehavebeencaseswhereROCKhasbeencourtorderedtoshareinformationaboutyourchild’sserviceandwehavehadtodoso.

PrintName SignatureofParent/Guardian Date

PrintName SignatureofParent/Guardian Date

PrintName SignatureofParent/Guardian Date