Custody Declaration
I, hereby authorize, with the total understanding of the above-mentioned terms and conditions, my child to receive mental health treatment at Shaysa Villa PLLC 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 Shaysa Villa PLLC 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. 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), Shaysa Villa PLLC 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 Shaysa Villa PLLC 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 Shaysa Villa PLLC is only requesting any and all related documents for the benefit of my child and therefore release any liability to Shaysa Villa PLLC , 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 Shaysa Villa PLLC 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.
