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Parent Information

Parent Name(Required)
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If the child’s caregivers are divorced then a copy of the complete divorce decree MUST be provided to Sheila Wessels Therapy before the family will receive services.

Consenting Caregiver

Please provide the name, phone number and email address of the other consenting caregiver. If you have sole custody, please type N/A.
Consenting Caregiver Name(Required)
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Other