Family Services Durham Child Counselling Declaration and Consent for Services

This form is to be completed and submitted by each parent/caregiver who is providing consent for service on behalf of a child. Each parent/caregiver providing consent must submit a separate form.

Parent/Caregiver/Guardian first and last name (required)

I declare that I am the parent/caregiver/guardian of the following child(ren):

Child's first and last name (required)

Date of birth (required)

Child's first and last name (required)

Date of birth (required)

Child's name first and last name (required)

Date of birth (required)

Child's first and last name (required)

Date of birth (required)

Add Remove

On the list below, please select the “Parent/Caregiver Arrangement” that reflects your family’s current situation. If you are unsure, speak with your Counsellor.

If there is a court order specifying custody or decision-making authority and/or conditions regarding counselling, a copy must be submitted to your Counsellor before your child receives service. It can be attached to this form, or submitted separately by email or in hard copy.

If desired, click here to attach a court document:

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My signature below confirms my consent for the child(ren) listed on this form to participate in service at Family Services Durham.

I have read and understood the Client Information Sheet and have discussed any questions with the Counsellor.
I understand that this consent may be withdrawn at any time by me or by Family Services Durham and that withdrawal of consent is not retroactive and may be subject to exceptions.
I understand that unless revoked, this consent will remain valid for one (1) year after the date of signing.

By signing below, I acknowledge I have read and understood the above and acknowledge that if signing on behalf of a minor or incapable person I have the authority to do so.

Enter your first and last name (required):

Date (required):

Enter your primary email address (required only if signing electronically):

I acknowledge that checking this box has the same force and effect as signing the document in person (required only if signing electronically):

I agree

Add your signature (not required if signing electronically):

Clear

Personal information and personal health information collected on this form is collected under the authority of the Personal Health Information Protection Act, 2004 (PHIPA) and will be used by Family Services Durham for the purpose of assessing eligibility and providing counselling services. This information will be handled in accordance with PHIPA and may be disclosed in accordance with applicable legislation if required. Questions regarding the collection, use or disclosure of your personal information or personal health information should be directed to the Corporate Privacy Office at privacy@durham.ca or 905-668-7711 ext. 2050 / 1-800-372-1102.