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Child Custody Attestation

Child's Name:

Date of Birth:

Parent / Legal Guardian:

Relationship to Child:

Custody Statement

I am the child's parent or legal guardian.

I have legal authority to consent to mental health services for this child.

If custody is shared, name of other parent/guardian:

Signature of Parent / Legal Guardian

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

April 2, 2026 9:46 am PDT

Child Custody Attestation Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.1

April 2, 2026 9:55 am PDT

Main Email - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.1