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October 7-9, 2017 (Columbus Day Weekend) Jenkintown, PA

Information in this application is HIPPA-compliant and is submitted to a confidential database that only our clinicians/staff can access.

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Participant Information
calendar
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)®.