Selective Mutism CAMP Interest Form

Rockville Therapy Center LLC

Founder, Dr. Lindsay Scharfstein Confident Kids Camp - DC drscharfstein@therapyrockville.com www.therapyrockville.com

301-245-6260

Confident Kids Camp DC Metro Request for Information

Today's Date

How did you hear about us?

Provide the name of the person/practice/website who referred you

Has your child attended to our Confident Kids Camp-DC before?

Yes, returning camper. No, new camper

What are your preferred next steps?

We are ready to sign up! Set us up in your system to complete the Registration Packet! We are new to this! Set us up with a free 15 minute call to discuss camp.

Child First Name

Child Last Name

Child Nickname/Preferred Name

Date of Birth

Current Age

Age at Camp Start 8/3/2026

Grade/Year in School

Name of School

Parent #1 First Name

Parent #1 Last Name

Parent #1 Email

Parent #1 Phone Number

Parent #2 First Name

Parent #2 Last Name

Parent #2 Email

Parent #2 Phone Number

Pediatrician Name/Practice

Psychiatrist Name/Practice

write NA if not applicable

Therapist Name/Practice

write NA if not applicable

Full Home Address

What services, if any, have you received in the past or currently receiving for your child's SM? If none, write no services yet.

Full Name of Person Completing this Form

What Happens After You Submit Your SM Camp Interest Form?

Great news — registration is now open! Once you submit your form, here’s what to expect:

✨ Our team will reach out within 3-4 business days with your Registration Packet and next steps.
✨ Didn’t hear from us yet? Feel free to follow up — we’re happy to help!
📧 Fastest: camp@therapyrockville.com
📞 Phone: (301) 245-6260

Please note: Submitting the SM Camp Interest Form does not confirm your child’s registration. It simply holds your place in line to receive the Registration Packet and enrollment instructions.

You can also find detailed registration steps and FAQs anytime at:
🌐 https://therapyrockville.com/camp/

We’re excited for another summer of brave moments and big wins!

Thank you from Rockville Therapy Center LLC and the Confident Kids Camp Team!

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