Services Request Form

Rockville Therapy Center LLC

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

301-245-6260

Thanks your interest in services at Rockville Therapy Center LLC!

To request services, please complete this form to build your profile in our system. We currently serve individuals and families coping with Selective Mutism, Social Anxiety, Anxiety, and Tics/Tourette's, and will provide referrals for all other areas.

Appointments are in-person on Mondays and Wednesdays, and virtual on Thursdays, from 9 am to 5 pm (new client openings are often before 3 pm).
We do not accept insurance. Clients pay upfront and receive a monthly Superbill on the 1st of each month via our Client Portal that details all services, codes, diagnoses, dates, and costs.
Child Services: All parent/legal guardian contact information must be included in this form.

Once you submit this form, it will be reviewed within 1 week. You will be contacted via email to either: a) schedule a brief 15-minute no-cost initial phone screen, or b) receive 2-3 referral options to other providers whose specialties might better serve you and/or your family's needs.

After the phone screen, if there is an appropriate fit, you will be added to the waitlist for services. When an opening becomes available, you will receive an email to complete the Intake and Consent Forms and schedule the Initial Evaluation appointments. For child services, all parents/legal guardians must complete all forms.

We cannot provide a time estimate but assure you that you will be contacted.

For questions or to check on the status of your request, contact us! New Clients: info@therapyrockville.com and SM Camp Clients at camp@therapyrockville.com

Thank you, and take good care!

Rockville Therapy Center LLC

Today's Date

How did you hear about us? Provide the specific name of the person/practice/website who referred you

For Parents seeking services for a CHILD (under age 18):

(skip to the next section if you are an adult seeking services for yourself)

Child First Name

Child Last Name

Child Nickname/Preferred Name

Email address

Phone Number

Date of Birth

Age

Grade 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

Nature of Concern? What brings you/your family to therapy (Check all that apply)

Selective Mutism - Individual, Family, School Only (no camp)

Selective Mutism - Winter Mini Camp

Selective Mutism - Summer 5-day Camp

Tics or Tourette's

Teen Social Anxiety

Autism Spectrum

Other

For ADULTS seeking services:

First Name

Last Name

Nickname/Preferred Name

Email address

Phone Number

Full Home Address

Date of Birth

Age

Occupation/Schooling

Physician Name/Practice

Therapist Name/Practice

write NA if not applicable

Psychiatrist Name/Practice

write NA if not applicable

Nature of Concern?

Selective Mutism

Tics or Tourette's

Teen Social Anxiety

Other

Full Name of Person Completing this Form

What To Expect After Submitting Your Service Request Form:

For non-wait-listed services, we should contact you with-in 2-5 business days. After this period, you may also follow-up with Dr. Scharfstein at info@therapyrockville.com, or for camp inquiries, camp@therapyrockville.com. The practice phone number (301) 245-6260. We, unfortunately, are unable to provide status updates and/or projections for wait-listed services. In the meantime, please learn more about the practice at https://therapyrockville.com/. With appreciation and gratitude!

Thank you from Rockville Therapy Center LLC!

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