APPLICATION FORM

Selective Mutism Course

6-WEEK EDUCATIONAL PROGRAM, LIVE VIA ZOOM

Interested families are encouraged to complete the application form below. A member of our team will then be in touch to discuss next steps.

All information is kept strictly confidential. Submission of this form goes not guarantee enrollment. If this is an emergency, please do not complete this form and instead call 9-1-1 or go to your nearest emergency room.

What is your name?

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How old is your child?

Where do you live?

Which course are you interested in?

How did you hear about us?

Please briefly describe your child's treatment journey, to date.

Is there anything else you'd like us to know before we speak with you?

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