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I/We have legal custody or guardianship of the following child or children
I/We give consent for him/her/them to receive individual and/or family
therapy.
Legal Custodial Parent/Guardian Signature
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Month
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Day
Year
Date
Legal Custodial Parent/Guardian Signature
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Month
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Day
Year
Date
Therapist's Signature
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Month
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Day
Year
Date
Submit
Should be Empty: