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CHILD CUSTODY SIGNATURE STATEMENT

FAMILY CONTACTS (If Applicable)


RESPONSIBLE/GUARANTOR INFO


1. The minor(s) named below live in my home and I am 18 years of age or older.
Yes
No
4.Your relationship to child(ren):
5.I hereby swear that I have the following legal custody (circle appropriate):
6.I hereby swear that I have a legal right to obtain treatment for the above-named child(ren):
Yes
No

  1. In instances of divorce, it is essential that the legal custodian of the child(ren) grant permission for the services.  If you are a divorced parent, a stepparent, a grandparent, a guardian, or other, you may be asked to provide a copy of the court order which names you the legal custodian of the above child(ren). 

Are you willing to do so?
Yes
No

If the answer to any of the above questions is “No,” counseling services can not be provided to the above-named child(ren) until a copy of the court order which names you the legal custodian is provided to this office.


  • I have read, understand, and agree to the Confidentiality Statement and the Informed Consent/Duty to Warn (exceptions to confidentiality) for Holistic Elevation.  

  • I am aware of its content and policies and understand that a copy of this Signature Statement will be a part of my case record.  

  • I have read it and if necessary, I have discussed and clarified my understanding of it with a representative of the Holistic Elevation.  

  • I agree to abide by the terms/policies set forth in this document.  

  • I consent to have the above-named minor(s) receive therapeutic services provided through Holistic Elevation without a parent or guardian present. 

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