Non-Consent By Parent Form (Minor Child Custody) printable pdf download

NON-CONSENT BY PARENT

I, ___________, am the father/mother of the minor child(ren) subject to this non-consent

who is/are:

Current Name

Gender

Birth date

School

___________________

________

__________

_________________________

I do not relinquish all rights to, custody of, and time sharing with this/these minor

child(ren), _____________. I can provide an environment for __________ that is not

dangerous, and I will prevent ________ from causing serious bodily harm to anyone in the

near future. I will provide a safe environment and care for ___________, with full

knowledge of the legal effect of this non-consent.

I understand my legal rights as a parent and I understand that I do not have to sign this non-

consent and do not release my parental rights. I acknowledge that this non-consent is

being given knowingly, freely, and voluntarily. I further acknowledge that my non-

consent is not given under fraud or duress. I do not give up my parental rights to and

interest in this/these minor child(ren), and this non-consent may only be withdrawn if the

Court orders it. I do not voluntarily relinquish all my parental rights to this minor child,

and I give no permission for psychiatric examination for any purpose.

I do not consent, release, and give up permanently, of my own free will, my parental rights

to this/these minor child(ren), for the purpose of psychiatric examination.

I do not waive any notice of ________’s removal from school grounds for the purpose of

psychiatric examination. I want to be contacted in the event that involuntary psychiatric

examination is being considered.

I understand that pursuant to Chapter 394, Florida Statutes, ________ can only be

psychiatrically examined if "Without care or treatment, the person is likely to suffer from

neglect or refuse to care for himself or herself; such neglect or refusal poses a real and

present threat of substantial harm to his or her well-being; and it is not apparent that such

harm may be avoided through the help of willing family members or friends or the

provision of other services."

I am a willing family member, and intend to seek other services if necessary.

I understand that I am swearing or affirming under oath to the truthfulness of the

claims made in this non-consent and non-waiver and that the punishment for knowingly

making a false statement includes fines and/or imprisonment.

Non-Consent By Parent Form (Minor Child Custody)