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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)

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
For questions, email: 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
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? *
Persons with Legal Custody of Child
1. Your Name & Relationship to Participant: *
Are you married to child's mother? *
Are you married to child's father? *
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 (can he or she go to the bathroom without help from parent)? *
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Information included is part of Social Communication Anxiety Treatment (S-CAT)®.