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October 7-9, 2017 (Columbus Day Weekend)

Participant Information
Is the child a current or former patient of the SMart Center? *
Primary Adult Contact
Relationship to Participant: *
Primary Adult Contact 2 (if applicable)
I, the applicant, authorize the SMart Center to disclose information regarding [the child] and CommuniCamp™ with [Adult Primary Contact 2].
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)®.