Application for February 2021 VIRTUAL CommuniCamp™ --President's Weekend!

Virtual CommuniCamp for Children and Parents!
Via Microsoft Teams

Ages 4-11 yr olds (special considerations for 12, 13 yr olds)

DATE/TIME:
Friday, February 12th, 2021 (1 PM EST - 5 PM EST)

Saturday, February 13th, 2021 (11 AM - 5 PM EST)

Sunday, February 14th, 2021 (11 AM - 5 PM EST)

Monday, February 15th, 2021 (11 AM - 5 PM EST)

Fee: $1450
(Plus intake/Interview+ for families new to the SMart Center)
Financial assistance avail.

Fri consists of parent education and meet/greets with parents/children, etc.
Sat, Sun, Mon consists of 2-3+ hours of parent education/support
3+ hours of parent/child skill building, facilitatiom of strategies led by clinical counselors.

** Please note that each day includes parent-only sessions and parent/child sessions. Breaks are build within schedule.

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 www.CommuniCamp.org.
For questions, email: CommuniCamp@SelectiveMutismCenter.org or set up a time to speak to our clinical staff about CommuniCamp.

Save & Return

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

Check off which CommuniCamp(s) you are interested in attending

Participant Information

Child's First Name *

Child's Last Name *

Birth Date * 🛈

Age *

Grade

Gender *

Child's Race/Ethnicity *

Today's Date * +

On a scale of 1 (not interested) to 10 (very interested), how would you rate your teen's desire to receive 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? *

Yes

No

If yes, when was their last appointment at the SMart Center?

Persons with Legal Custody of Child

1. Your Name & Relationship to Participant: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Country *

Cell Phone *

Alternate Phone

Email Address *

Are you married to child's mother? *

Yes

No

Are you married to child's father? *

Yes

No

Persons with Legal Custody of Child

2. Relationship to Participant:

Mother

Father

Guardian

Other Other

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Whom does this child live with on a regular basis?

Select all that apply: *

Mother

Father

Guardian

Other Adults and Children Living in the Child's Home

Please list name/age/gender/relationship of all other adults and/or children living with the child, if not listed above. Include step-siblings, foster children, and related and unrelated adults.

Can this person(s) correspond with the SMart Center regarding child?

Yes

No

Best Person to correspond with regarding child's appointments and case (if different from person(s) with legal custody):

First Name

Last Name

Relationship to Child:

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Medical Information

Diagnoses (check all that apply) *

Has your child ever received treatment/services? *

Yes

No

If yes, please specify below.

Is your child toilet-trained (can he or she go to the bathroom without help from parent)? *

Yes

No

If yes, has he or she had any accidents in the past six months? Please explain. *

Does your child have any medical or physical problems? Allergies? *

Please list any medications your child is currently taking. *