CommuniCamp Logo

SAT DEC 12 2020 Participant Application for 1- Day Virtual CommuniCamp™ for Children (& Their Families!) Ages 4-11 (Special considerations for 12, 13 yr olds)

Information in this application is HIPAA-compliant and is submitted to a confidential database that only our clinicians/staff can access. For more details including pricing, enrollment process, treatment approach, financial assistance, agenda, FAQs, and more, visit

Save & Return

Save your progress & return later. (Optional but encouraged. The application is thorough and comprehensive and may take 30-45 minutes to complete.)

Participant Information
Is the child a current or former patient of the SMart Center? *
Persons with Legal Custody of Child
1. Your Name & Relationship to Participant: *
Are you married to the child's father? *
Are you married to the child's mother? *
Persons with Legal Custody of Child
2. Relationship to Participant:
Whom does this child live with on a regular basis?
Select all that apply: *
Other Adults and Children Living in the Child's Home
Can this person(s) correspond with the SMart Center regarding child?
Best Person to correspond with regarding child's appointments and case (if different from person(s) with legal custody):
Medical Information
Diagnoses (check all that apply) *
Has your child ever received treatment/services? *
Is your child toilet-trained (can he or she go to the bathroom without help from parent)? *
Secured by Formsite
Copyright© Dr. Elisa Shipon-Blum and Selective Mutism Anxiety Research & Treatment Center (SMart Center). Users are responsible for complying with all copyright and licensing restrictions.
Information included is part of Social Communication Anxiety Treatment (S-CAT)®.