Declaration and Consent
I/We, being the custodial parent(s)/guardian(s) of the above named child, consent to the assessment and/or treatment services of said child at the Possibilities Clinic.
I/We agree to inform the clinic, should this arrangement be changed while receiving the services at Possibilities Clinic.
I/We agree if I am unable to attend any appointment with one parent, and wish to have an appointment for myself, there would be an additional charge for that appointment, if Possibilities Clinic is able to provide it.
I/We understand that both parents will have access to the child's complete chart at Possibilities Clinic. Please note that the chart includes all communications from both parents, including all emails and telephone calls. Please note that non-custodial parents and parents without decision making authority retain access to the chart, unless there is a court order stating otherwise.