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

Thank you for your interest in services at the Rockville Therapy Center LLC!

To request services, please provide complete information in this form to build your profile in our system. We currently serves individuals and families coping with Selective Mutism, Teen Social Anxiety, and Tics/Tourette's. Referrals will be provided for all other areas. Appointments are held in person (M/W) and virtually (M/W/Thu), during the hours of 9am to 5pm (4pm is the latest appointment time).

Once you submit this form, it will be reviewed within 1 week. At that time, you will be contacted by email to either: a) schedule a brief (15-minute) no-cost initial phone screen, or b) we will provide you with 2-3 referral options of other providers and practices whose specialities might better serve you and/or your family's needs.

After a completed phone screen, and when there is an appropriate fit, you will be added to the waitlist for services. When an opening becomes available, you will be contacted by email to complete the Intake and Consent Forms and Schedule an Initial Evaluation appointment. For child services, both/all parents/legal guardians must complete all Forms.

Unfortunately, we are unable to provide a time estimate but want to assure you that you will be contacted. If you have any questions, or would like to check on the status of your request, contact us:

For selective mutism camp services, please email us camp@therapyrockville.com

For individual or group therapy services, please email us info@therapyrockville.om

Email is our fastest means of communication, though you are welcome to call us at (301) 245-6260 to leave a detailed message.

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

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

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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