Selective Mutism CAMP Services Request Form

Rockville Therapy Center LLC

Founder, Director, 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

Child First Name

Child Last Name

Child Nickname/Preferred Name

Date of Birth

Current Age

Age at Camp Start (7/29/2024)

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.

Child has been to our Confident Kids Camp before?

Yes, returning camper. No, new camper

What are the 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.

Full Name of Person Completing this Form

What To Expect After Submitting Your Service Request Form:

Registration opens in January. If you contact us before then, you will be contacted in January. If registration is open, we should contact you within 2 business days. After this period, you may also follow-up with our Camp Coordinator at camp@therapyrockville.com (fastest) or (301) 245-6260.

Please Note: Camp is FULL.

Submitting this Services Request Form does NOT confirm registration.

Detailed information about the Steps to Registration as well as answers to frequently asked questions (FAQs) can be found on our website at https://therapyrockville.com/camp/

Thank you from Rockville Therapy Center LLC!

Your information will be encrypted.

Selective Mutism CAMP Services Request Form

Rockville Therapy Center LLC

Confident Kids Camp DC Metro Request for Information

What To Expect After Submitting Your Service Request Form:

***Please Note: Camp is FULL.***

Submitting this Services Request Form does NOT confirm registration.

Thank you from Rockville Therapy Center LLC!

Rockville Therapy Center LLC

Please Note: Camp is FULL.