Please fill out the information below and then click submit after you have finished. You will need to send in your full payment before a spot can be officially reserved for your child(ren). $50.00 per child
(If more than 1 child - $ 100.00 maximum)
You can mail your payment to: Peaceful Solutions Counseling, 1720 Merrill Ave, Wausau, WI 54401
Child Name # 1 DOB:
Child Name # 2 DOB
Child Name #3 DOB
Child Name # 4 DOB
Mother's Name:
Mothers Address
Mothers daytime phone:
Mothers Home Phone:
Fathers Name
Fathers Address
Fathers daytime phone:
Fathers Home Phone
Parent filling out this form:
Choose which group and date you are signing up for. Choose date and group that is appropriate for your child's age. If you have more than one child, select more than one group.
Age 6- 8
Age 9-11
Age 12-13
Age 14-17
Is this program mandated by The Family Court Commissioner or Judge:
Any specific medical condition or dietary concern we should be aware of during those three hours? If yes, please explain:
E-Mail address for us to send confirmation to (optional):
If the form is complete, Click submit and we will put your child on the list. However, please understand that we will not officially reserve a spot until payment is made. Group size is limited! Also, please understand that if we do not have enough to fill a group (less than 5), we will need to postpone the group until the next available group. You will be notified as soon as we make that decision.
Thank you. We hope this experience for your child(ren) will be a positive and healing experience!
If you have no ability to pay and fall within the 150 % of 2010 Poverty Guidelines (see below), and wish to inquire about a reduced fee, please call our office to obtain an application. Please understand that we will request documentation and proof of income, along with your completed application.
Online Registration for the Butterfly Program
"Just when the catapillar thought the world was over, it became a butterfly"
