CommuniCamp Logo

August 17th - 20th 2018 in Jenkintown, PA

Information in this application is HIPAA-compliant and is submitted to a confidential database that only our clinicians/staff can access. For dates, times, pricing, FAQs, and to learn more, visit www.CommuniCamp.org.

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
calendar
On a scale of 1 (not interested) to 10 (very interested), how would you rate your teen's desire help to socialize and communicate with others? *
On a scale of 1 (not interested) to 10 (very interested), how would you rate your teen's desire to participate in this program? *
Is the child a current or former patient of the SMart Center? *
Persons with Legal Custody of Child
1. Relationship to Participant: *
 
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? *
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Information included is part of Social Communication Anxiety Treatment (S-CAT)®.