CommuniCamp Application

SMart Center
505 Old York Rd
Jenkintown, PA, 19046
www.selectivemutismcenter.org

Participant Information

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Is the child a current or former patient of the SMart Center? *

Household / Adult Primary Contact

Relationship to Participant: *
 

Medical Information

Diagnoses (check all that apply) *
 
Has your child ever received treatment/services? *
Is your child toilet-trained? *
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Information included is part of Social Communication Anxiety Treatment (S-CAT)®.